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EPILEPSY 


AND 


ITS     TREATMENT 


BY 

WILLIAM  P.  SPRATLING,  M.D. 

Medical  Superintendent  of  The  Craig  Colony  for  Epileptics;  Secretary 
of  The  National  Association  for  the  Study  of  Epilepsy  and  the  Care 
and'  Treatment  of    Epileptics ;    Member  American    Medico- 
Psychological  Association,  New  York  Academy  of  Medi- 
cine,  Buffalo  Academy  of    Medicine,   Rochester 
Pathological  Society,  American  Medical 
Association,  etc. 


jfulls  IFllustrateD 


PHILADELPHIA,   NEW  YORK,   LONDON 

W.   B.   SAUNDERS   AND   COMPANY 
1904 


Copyright,  1904, 
By  W.  B  Saunders  &  Company. 


DEDICATED 

IN 

GRATEFUL  AFFECTION  AND  ESTEEM 

TO 

PROFESSOR   JOHN   WESLEY   CHAMBERS,  M.D., 

OF 

The  College  of  physicians  and  Surgeons, 
baltimore,  md., 

MY  PRECEPTOR  AND  FRIEND. 


PREFACE. 


The  great  progress  made  in  the  knowledge  of  epi- 
lepsy and  its  treatment  during  the  past  decade  and 
a  half,  and  the  fact  that  no  complete  treatise  on  the 
subject  has  appeared  in  the  United  States  since  Eche- 
verria's  work  was  published  thirty-three  years  ago, 
were  the  chief  reasons  that  led  to  the  preparation  of 
this  volume. 

In  all  that  it  treats  of,  including  Definition,  Classi- 
fication, Etiology,  Diagnosis,  Prognosis,  Pathology, 
Psychologic  and  Medicolegal  Aspects,  and  Treatment, 
it  is  designed  for  the  student  and  practitioner  of  medi- 
cine alike. 

To  present  all  sides  of  the  modern  care  and  treat- 
ment of  the  epileptic,  I  have  incorporated  in  the 
chapter  on  general  treatment  notes  on  the  education 
of  this  very  generally  neglected  class. 

The  past  few  years  have  witnessed  a  worthy  ten- 
dency to  amplify  the  work  of  the  physician  in  many 
cases  by  placing  the  patient  under  the  special  forms 
of  mental,  moral,  physical,  and  hygienic  regime  now 
so  greatly  in  vogue,  and  which  are  proving  of  such 
distinct  value. 

It  is  an  established  fact  that  the  best  results  from 
treatment  in  epilepsy  are  obtained  only  when  the 
individual,  as  well  as  his  disease,  is  recognized  and 
treated ;  and  in  this  work  it  has  been  my  aim  to  show 
how  this  may  be  most  effectively  accomplished. 

The  work  represents  the  author's  experience  as 
Medical  Superintendent  of  the  Craig  Colony  for  Epi- 
leptics at  Sonyea,  N.  Y.,  during  a  period  of  nearly  ten 


O  PREFACE. 

years;  the  care  and  treatment  of  a  large  number  of 
epileptics  in  the  New  Jersey  State  Hospital  at  Morris 
Plains,  and  his  previous  work  in  the  Department  of 
Neurology  of  the  Vanderbilt  Clinic,  Columbia  College, 
New  York. 

I  take  pleasure  in  acknowledging  my  indebtedness 
to  Dr.  Thomas  P.  Prout  and  Dr.  L.  Pierce  Clark  for 
the  valuable  contribution  they  make  in  the  chapter 
on  Pathology;  to  Dr.  Clark  for  the  chapter  on  Status 
Epilepticus,  and  for  permission  to  use  illustrations 
from  his  clinical  studies  in  epilepsy;  to  Dr.  E.  A. 
Sharp  and  Dr.  Robert  E.  Doran  for  aid  in  preparing 
data  under  Surgical  Technique;  to  Dr.  Pearce  Bailey 
for  critical  review  of  much  of  the  text;  to  Dr.  Fred- 
erick Peterson  and  Dr.  Joseph  D.  Bryant  for  use  of 
illustrations  from  their  books;  and  to  my  assistants 
at  Sonyea  for  aid  given  when  desired. 

The  author's  cordial  thanks  are  due  the  publishers 
for  making  "Epilepsy  and  Its  Treatment"  a  work  of 
credit  from  the  standpoint  of  the  bookmaker's  art. 


CONTENTS. 


INTRODUCTION. 

PAGE 

The  Synonyms  of  Epilepsy n 

CHAPTER  I. 
Definition   of  Epilepsy 14 

CHAPTER  II. 
Classification 18 

CHAPTER  III. 
Frequency,  Age,  Sex,  Race,  and  Occupation 46 

CHAPTER  IV. 
Etiology — Part  I 58 

CHAPTER  V. 
Etiology — Part  II 101 

CHAPTER  VI. 
Seizure  Types 139 

CHAPTER  VII. 
Status  Epilepticus 195 

CHAPTER  VIII. 
Forms  of  Epileptic  Aura 221 

CHAPTER  LX. 
Sequelae  of  Epileptic  Convulsions 247 

CHAPTER  X. 
Diagnosis 274 

CHAPTER  XL 
Prognosis 290 

CHAPTER  XII. 
Pathology  309 

CHAPTER  XIII. 
General  Treatment 33^ 

7 


8  CONTENTS. 

CHAPTER  XIV. 

PAGE 

Medical  Treatment 359 

CHAPTER  XV. 
Surgical  Treatment 393 

CHAPTER  XVI. 
Psychologic  Aspects 438 

CHAPTER  XVII. 
Medicolegal  Aspects 471 


Index 5°5 


EPILEPSY 


ITS  TREATMENT. 


EPILEPSY  AND   ITS  TREATMENT. 


INTRODUCTION. 

THE  SYNONYMS  OF  EPILEPSY. 

Epilepsy  is  from  the  Greek  word  wrfli^fcc,  a  seizure, 
from  £ndafipdveivf  "to  seize  upon." 

FROM  THE  LATIN. 

Morbus  Sacer. — The  sacred  disease;  so  called  be- 
cause the  priests  of  Apollo  and  the  Sibylline  priestesses 
were  either  in  epileptic  fits  just  prior  to  the  pronounc- 
ing of  prophecies,  or  pretended  to  be  so. 

Morbus  Major. — The  greater  disease;  referring  to 
the  severer  types  of  epilepsy  in  contradistinction  to 
the  milder  forms  of  convulsions  embracing  hysteria, 
chorea,  twitching  of  the  muscles,  etc. 

Morbus  Herculeus. — The  Herculean  disease;  so 
called  possibly  on  account  of  the  resistless  grasp  of 
the  attack,  but  more  probably  because  Hercules  was  a 
victim  of  it,  as  typified  in  the  story  of  the  garment  of 
Nessus.  After  the  destruction  of  Nessus,  Hercules  is 
said  to  have  made  a  shirt  of  the  hide,  and  having 
donned  it  could  never  get  it  off,  but  committed  suicide 
to  escape  its  torture.  Some  regard  this  story  as 
merely  a  figurative  description  of  the  last  stage  of 
epilepsy,  while  others  think  it  possible  of  better  inter- 
pretation. 

Morbus  Commitialis. — The  disease  of  assemblies; 
being  so  called  because  epileptic  attacks  always 
"had  the  right  of  way"  over  other  matters  in  an 
assembly  in  ancient  times,  all  business  being  suspended 


12  THE    SYNONYMS    OF    EPILEPSY. 

until  the  fit  was  over.  Superstition  and  not  sympathy- 
was  the  governing  cause  of  this  consideration. 

Morbus  Mensalis. — The  disease  of  the  table ;  in  this 
case  the  reference  is  doubtless  due  to  the  frequency  with 
which  convulsions  were  apt  to  appear  while  the  patient 
was  at  the  table. 

Morbus  Convivialis. — The  disease  of  feasts;  the 
meaning  in  this  case  is  substantially  the  same  as  that 
above. 

Morbus  Insputatis. — The  spitting  disease;  this  may 
be  more  graphically  than  elegantly  translated  as  the 
"slobbering  sickness." 

Morbus  Viridellus. — The  greenish  disease;  in  all 
probability  so  called  from  the  change  an  attack  effects 
in  the  complexion. 

Morbus  Vitriolatus. — The  vitriolate  disease;  prob- 
ably an  allusion  to  the  color  of  ferrous  sulphate, 
formerly  called  green  vitriol,  the  temporary  color  of 
the  face  during  an  attack  suggesting  it. 

Morbus  Sonticus. — The  serious  or  dangerous  dis- 
ease; in  Roman  law  it  meant  any  disease  excusing 
from  duty.  This,  by  the  growth  of  the  idea,  gradually 
came  to  mean  excusing  from  responsibility. 

Morbus  Caducus. — The  falling  sickness;  the  most 
commonly  used  of  any  of  the  ancient  designations. 

Morbus  Unicatus. — The  only  disease;  unicatus  is  a 
modern  Latin  word  probably  not  existing  in  Latin 
lexicons.  Professor  J.  W.  Lockhart,  a  noted  Latin 
scholar,  says:  "  I  suppose  it  is  used  in  this  connection 
because  it  means  there  is  no  other  disease  like  it, 
or  possibly  because  of  an  imagined  non-communi- 
cability  of  the  disease." 

Morbus  Fcedus. — The  filthy  disease;  so. called  be- 
cause it  produces  a  relaxation  of  the  excreting  orifices 
of  the  body. 

Morbus  Sideratus. — The  star-struck  disease;  sidus, 
in  this  connection,  was  loosely  applied  to  stars,  planets, 


FROM    THE    LATIN.  1 3 

and  the  sun.  The  ancients  often  thought  the  epileptic 
had  received  a  blow  from  a  star,  or  was  blasted  by 
the  influence  of  some  heavenly  body.  The  frequency 
of  the  visual  aura,  when  the  patient  sees  flashes  of 
light,  stars,  or  other  luminous  bodies,  may  have  helped 
to  bestow  this  name. 

Morbus  Scelestus. — The  criminal  disease;  alluding 
to  the  criminal  tendencies  it  frequently  develops. 
It  appears  that  the  term  is  applied  to  this  phase  of 
epilepsy  exclusively. 

Morbus  D&moniacus. — The  disease  possessed  by 
demons;  a  very  convenient  though  barbarous  form 
of  ancient  pathology.  It  usually  refers  to  the  raving 
phase  of  epilepsy. 

Morbus  Deiflcus. — The  God-making  disease;  it 
seems  that  epilepsy  acquired  this  name  because  of  its 
potency  in  increasing  the  priest's  reputation  for  sanc- 
tity. The  symptoms  of  this  phase  were  chiefly  those 
pertaining  to  religious  frenzy.  The  Greeks  called  it 
"The  Priestly  Disease." 

Morbus  Astralis. — This  is  only  another  form  for  the 
designation  of  the  Morbus  Sideratus,  the  star-struck 
disease  previously  described. 

Analepsia. — Grasping  upward;  to  seize  or  grasp, 
alluding  to  the  victim's  throwing  up  his  hands  while 
in  a  seizure  and  catching  at  nothing. 

Apoplexia  Parva. — Small  apoplexy. 

Passio  Caduca  et  Perdito. — The  falling  sickness, 
combined  with  a  tendency  to  destructiveness. 

The  Germans  call  it  epilepsie,  fallsucht;  the  French 
epilepsie,  grand  mat,  haut  mal,  petit  mal;  the  Italians 
refer  to  the  disease  as  epilepsia;  the  English  as  epilepsy 
or  fits;  while  its  Scandinavian  designation  is  epilepsia 
fallendsot. 


CHAPTER  I. 

DEFINITION  OF  EPILEPSY. 

It  is  exceedingly  difficult  to  define  a  disease  in  which 
changing  conditions  of  mind  are  prominent  and  essen- 
tial features — like  insanity,  for  instance — and  it  is 
even  more  difficult  to  define  a  disease  that  is  partly 
mental,  partly  physical;  more  the  former  at  one  time, 
more  the  latter  at  another. 

For  this  reason  it  is  well  that  we  are  seldom  called 
upon  to  define  epilepsy  in  a  single  phrase  or  term ;  but 
the  growing  medicolegal  importance  of  this  disease  in 
late  years,  an  importance  already  too  long  neglected, 
requires  that  physicians  on  the  witness-stand  should 
be  in  a  position  to  state  in  a  satisfactory  way  how 
epileps}^  in  its  great  variety  of  forms  affects  the  person 
who  has  it,  and  to  tell  in  more  or  less  general  terms 
what  the  malady  is  and  what  it  means. 

Any  one  called  upon  to  testify  in  this  way  would 
do  well  to  make  it  plain  that  epilepsy  is  one  of  the  most 
protean,  variable,  and  uncertain  of  all  maladies  com- 
mon to  the  human  race,  and  to  state  that  it  is  impos- 
sible to  describe  to-day  how  the  seizures  of  this  disease 
affect  a  given  individual  in  a  way  that  would  make 
the  same  description  applicable  to-morrow,  for  seizure- 
types  are  not  fixed  in  character  in  many  cases. 

If  urged,  however,  for  a  description  or  definition,  he 
would  do  well  to  quote  from  some  of  the  standard 
medical  writers  on  the  subject,  giving,  among  others, 
the  following: 

"The  characteristic  of  the  malady  is  the  recurrence 
of  sudden  brief  disturbance  of  some  function  of  the 

14 


DEFINITION    OF    EPILEPSY.  I  5 

brain,  varying  in  degree,  extent,  and  character,  but 
generally  attended  with  an  arrest  of  consciousness 
sufficient  at  least  to  interrupt  the  control  of  the  muscles 
necessary  for  the  maintenance  of  the  erect  posture." — 
(Sir  William  R.  Gowers.) 

"A  nervous  affliction  characterized  by  sudden  loss 
of  consciousness  and  power  of  motion,  with  tonic 
and  clonic  convulsions,  the  paroxysms  lasting  but 
a  short  time." — (Gould.) 

"Recurring  attacks,  sudden  and  very  brief,  of  dis- 
turbance of  some  of  the  cerebral  functions  acting  on 
consciousness,  which  are  not  due  to  a  cause  outside 
the  brain."— (Thomas  Clifford  Allbutt.) 

"Epilepsy  is  a  chronic  disease  of  which  the  charac- 
teristic symptom  is  a  sudden  trouble  or  loss  of  con- 
sciousness, this  change  being  occasional  and  tem- 
porary, sometimes  unattended  by  any  evident  mus- 
cular contraction,  sometimes  accompanied  by  partial 
spasm,  and  sometimes  by  general  convulsion.  The 
two  elements  probably  present  in  every  case  of  epilepsy 
are  diminution  of  intelligence  and  excess  of  muscular 
contraction,  and  these  two  elements  may  exist  in 
almost  every  degree  or  combination  and  be  developed 
to  any  degree  of  intensity." — (Russell  Reynolds.) 

"Epilepsy  is  a  disease  constituted  by  chronic 
paroxysms,  excited  upon  a  direct  reflex  action  of  the 
medulla  oblongata,  in  a  condition  of  exalted  irritability, 
coincident  with  sudden  depression  in  the  cerebral  cir- 
culation and  with  the  loss  of  consciousness,  with  or 
without  muscular  spasms." — (Echeverria.) 

In  defining  epilepsy  it  is  important  to  remember 
that  it  has  two  cardinal  forms  of  manifestation,  both 
of  which  are  present  in  the  majority  of  cases  during 
the  attack,  but  either  of  which  may  be  absent,  without 
the  case  losing  any  of  its  epileptic  character.  These 
manifestations  are:  First,  impairment  or  loss  of  con- 
sciousness; second,  impairment  or  loss  of  motor 
coordination.  This  being  true,  the  following  definition 
is  perhaps  as  satisfactory  as  any  that  can  be  formu- 
lated at  this  time: 

Epilepsy  is  a  disease  or  disorder  affecting  the  brain, 


l6  DEFINITION    OF    EPILEPSY. 

characterized  by  recurrent  paroxysms  which  are  abrupt 
in  appearance,  variable  in  duration  but  generally  short, 
and  in  which  there  is  impairment  or  loss  of  conscious- 
ness, together  with  impairment  or  loss  of  motor  coordina- 
tion, with  or  without  convulsions. 

Should  we  wish  to  make  the  essential  points  of  this 
definition  clearer,  we  might  present  the  matter  thus: 

First.  Impaired  or  lost  consciousness,  usually  sudden 
and  transitory; 

Second.  Impaired  or  lost  motor  coordination,  usually 
sudden  and  transitory; 

Third.  Either  condition  in  any  case  being  attended 
with  or  without  convulsions. 

All  phenomena  occurring  during  an  epileptic  attack 
group  themselves  about  the  pathologic  changes  in 
consciousness  and  in  motility.  If  neither  of  these  is 
disturbed,  there  can  be  no  epileptic  attack. 

There  are  epileptics  who  simply  "forget,"  have 
"weaknesses,"  "flashes,"  "faints,"  "absences," 
"blanks,"  and  "  darknesses,"  which  may  last  but  a  few 
seconds  or  less,  or  may  be  prolonged  for  days  at  a 
time,  during  which  the  individual's  physical  com- 
posure is  in  nowise  disturbed.  Such  attacks  constitute 
what  the  author  has  designated  as  the  "silent  forms  of 
epilepsy."  On  the  other  hand,  there  are  epileptics 
who  pass  through  the  most  violent  and  general  mus- 
cular contractions,  during  which  there  is  enough 
consciousness  left  for  the  individual  to  distinguish  to 
some  extent  what  is  going  on  about  him  and,  to  some 
extent,  remember  and  tell  of  it  afterward. 

Sooner  or  later  we  may  come  to  differentiate  such 
convulsions  as  these  from  "true' '  epilepsy,  calling  them 
epileptiform  or  epileptoid;  for  it  is  notable  that  the 
minds  of  such  patients  rarely,  if  ever,  show  impairment 
or  disease  during  the  interparoxysmal  periods,  like 
the  minds  of  those  whose  convulsions  have  a  larger 
element  of  psychic  or  intellectual  disturbance  in  them. 


DEFINITION    OF    EPILEPSY.  1 7 

At  the  same  time,  we  must  bear  in  mind  the  fact  that 
a  localized  irritant,  directly  or  reflexly  affecting  the 
motor  centers,  is  capable  of  producing  in  time  genuine 
convulsions  in  which  consciousness  may  not  always  be 
entirely  destroyed,  especially  during  the  earlier  periods 
of  the  disease. 

What  is  now  called  habit  epilepsy  comes  under  this 
head,  meaning  a  type  of  the  disease  due  at  first  to  a 
focal  irritation,  central  or  peripheral,  which  being 
unremoved,  creates  a  distinct  pathologic  basis  for  its 
existence  simply  through  the  effects  of  the  convulsions 
often  repeated;  and  so  it  is  that  simple  convulsions 
may  in  time  pass  into  genuine  epilepsy,  whereas 
primarily  true  epilepsy  is  never  transformed  into 
simple  or  reflex  convulsions. 


CHAPTER  II. 
CLASSIFICATION. 

Based  on  Symptomatology :  Grand  Mai;  Petit  Mai;  Psychic;  Jacksonian. 
On  Etiology  (tentative  and  in  part):  Infantile  Inherited;  Accidental; 
Traumatic;  Idiopathic.  Similar  Causes  Active  in  Different  Proportions 
in  Early  and  Adult  Life:  Developmental;  Toxic;  Senile.  Method  of 
Examining  for  Epilepsy. 

CLASSIFICATION  BASED  ON  SYMPTOMATOLOGY. 

Notwithstanding  the  remarkable  progress  that  has 
been  made  during  the  past  twelve  or  fifteen  years  in 
studying  the  etiology  of  epilepsy,  both  remote  and 
immediate,  such  study  has  not  proceeded  far  enough, 
and  the  time  is  not  yet  ripe  for  permitting  a  satisfac- 
tory classification  based  on  etiology. 

In  order,  however,  to  show  in  a  measure  the  lines 
along  which  research  is  being  conducted  in  attempting 
to  locate  causes,  it  seems  well  to  present  a  tentative 
classification  based  on  what  we  know  about  etiology 
at  this  time.  This  will  be  presented  after  a  description 
has  first  been  given  of  the  very  satisfactory  classifica- 
tion now  in  use  which  is  based  wholly  on  symptomat- 
ology. 

The  latter  classification  is  something  of  an  anomaly 
in  nomenclature,  made  up  as  it  is  of  Greek,  French, 
and  English  terms,  requiring  parts  of  three  languages 
to  express  its  four  simple  designations,  which  are  as 
follows : 

Grand  Mai. 

Petit  Mai. 

Jacksonian. 

Psychic. 

In  grand  mal  we  have  a  designation  which  describes 


CLASSIFICATION    BASED    ON    SYMPTOMATOLOGY.      19 


the  severest  form  of  epilepsy,  the  literal  meaning  of 
the  words  being  great  or  severe  illness. 

By  petit  mal  is  meant  a  fit  or  seizure  of  lesser  mag- 
nitude, a  "little  sickness,"  so  to  speak,  both  terms  in 
this  case  being  purely  French. 

The  third  designation,  Jacksonian,  is  a  term  applied 
to  a  form  of  monospasm;  convulsive  movements  con- 
fined to  one  arm  or  leg,  to  one  side  of  the  face,  or  to 
a  single  group  of  muscles.  Attention  was  first  called 
to  this  irregular  and  partial  form  of  the  disease  by 
Hughlings- Jackson,  of  England,  in  1866. 

In  the  last  form  we  employ  a  derivative  from  the 
Greek,  0u/«<k  {4>i>yrh  soul,  mind),  meaning  psychic  or 
psychical,  its  further  meaning  being  "of  or  pertain- 
ing to  the  mind  or  soul ;  mental  as  distinguished  from 
physical  and  physiologic." 

Now,  in  order  to  fix  this  practical  classification  in 
mind,  we  ought  to  have  some  knowledge  of  the  type 
of  disease  described  by  each  variety.  The  following 
simple  arrangement  is  offered  as  affording  all  that 
seems  to  be  required : 

A  severe  fit,  the  worst  form  of  epilepsy. 

One  in  which  consciousness  is  always  lost,  and  in  which 
motor  coordination  is  completely  destroyed. 

In  such  attacks  the  patient  always  falls  or  is  thrown  to 
the  ground,  generally  with  great  violence. 

A  mild  fit. 

One  in  which  consciousness  need  not  be  entirely  lost; 
nor  is  motor  coordination  of  necessity  entirely  destroyed. 

In  petit  mal  attacks  the  patient  may  not  fall  or  be  thrown 
to  the  ground,  although  there  is  some  muscular  involve- 
ment, either  general  or  local. 

A  form  of  monospasm,  the  convulsive  movements  being 
confined  to  one  leg  or  arm,  or  group  of  muscles,  and  in 
which  consciousness,  as  a  rule,  is  not  lost. 

The  patient  seldom  falls  or  is  thrown  to  the  ground, 
during  the  earlier  stages  of  the  disease,  at  least. 

Amplification  of  Jacksonian  attacks  may  in  time  cause 
complete  loss  of  consciousness  and  muscular  control — 
graiid  mal,  in  other  words. 

A  seizure  of  the  mind,  leaving  the  body,  as  a  rule,  un- 
disturbed. 

A  temporary  blank  in  the  field  of  consciousness. 

A  pathologic  lapse  in  memory,  varying  from  a  second  or 
two  up  to  days  and  even  weeks,  and  rarely  accompanied 
by  muscular  disturbance  of  any  kind. 


Grand  Max  ■ 


Petit  Mal     \ 


Jacksonian 


Psychic 


20  CLASSIFICATION. 

Because  of  its  simplicity  and  its  long  usage,  this 
classification  has  much  to  commend  it,  especially  to 
the  student  of  medicine  and  the  busy  practitioner 
seeking  to  understand  some  of  the  fundamentals  of 
the  disease  without  being  obliged  to  study  in  detail 
the  vast  array  of  long,  tedious,  scientific  terms  essential 
to  a  classification  founded  on  a  multitude  of  causes. 

At  the  same  time,  this  seemingly  simple  classification 
is,  after  all,  based  on  a  scientific  footing  relating  to 
the  anatomy  and  physiology  of  the  brain.  Thus,  if  a 
grand  mal  attack  suspends  or  temporarily  destroys  all 
the  functions  of  the  brain,  including  consciousness, 
the  special  senses,  and  motor  coordination,  we  can  at 
once  understand  that,  whatever  is  the  lesion  or  process 
back  of  the  fit,  it  affects  the  entire  brain  mass,  either 
simultaneously  or  in  an  almost  inconceivably  rapid 
order  of  invasion. 

If  a  petit  mal  attack  serves  only  to  produce  slight 
muscular  spasms,  which  may  cause  the  patient  to 
stagger  but  not  to  fall  or  be  thrown  to  the  ground,  and 
some  mental  confusion  that  soon  passes  away  without 
being  followed  by  unconsciousness  or  coma,  we  can 
understand  that  the  process  in  the  brain  in  this  case 
may  be  general  in  character,  but  not  very  severe ;  the 
essential  difference  between  attacks  like  these  and 
those  of  grand  mal  being  largely  one  of  intensity, 
duration,  and  degree.  The  same  applies  to  the  Jack- 
sonian  attack. 

It  is  clear  that  the  contraction  of  isolated  groups  of 
muscles,  or  the  spasmodic  movements  of  one  leg  or 
arm,  need  have  but  little,  if  any,  effect  on  the  mind, 
as  they  are  due  to  a  localized  lesion  in  some  part  of 
the  motor,  cortex  of  the  brain.  The  psychic  attack 
acts  simply  by  temporarily  blotting  oub  the  faculties 
of  the  mind — just  that  and  nothing  else,  producing  no 
motor  disturbance  whatever.  It  must,  therefore,  have 
its  causal  elements  in  the  parts  of  the  brain  occupied 


CLASSIFICATION    BASED    ON    SYMPTOMATOLOGY.      2  1 

by  the  so-called  organs  of  the  mind,  which  the  weight 
of  teaching  of  modern  physiology  seems  to  agree  in 
locating  in  the  frontal  lobes. 

There  is  apt,  as  a  rule,  to  be  some  confusion,  some 
difficulty  in  differentiating  attacks  of  psychic  epilepsy 
from  those  of  petit  mal,  but  it  is  our  belief  that  they 
constitute  easily  distinguishable  types.  It  will  not  be 
out  of  place  here  to  describe  what  these  differences  are, 
illustrating  them  by  reference  to  two  cases : 

E.  S.,  an  epileptic  woman  of  middle  age,  sat  at  the 
table  near  my  desk  directing  envelopes  from  a  printed 
list  of  names. 

I  happened  to  be  observing  her  at  the  time  and 
noticed  that  she  kept  writing  the  same  name,  putting 
it  down  seven  times  altogether.  While  doing  this  the 
only  noticeable  changes  in  her  condition  were  a  slight 
drooping  about  the  corners  of  the  mouth,  a  set,  staring 
expression  of  the  eyes,  and  some  pallor  of  the  face. 

There  was  absolutely  no  impairment  of  the  action 
of  any  of  the  muscles  used  in  writing ;  no  sound  of  any 
kind  escaped  her;  no  disturbance  whatever  of  body 
posture;  the  chief  evidence  of  an  attack  being  the 
repetition  in  writing  of  the  same  name  seven  times, 
which  represented  a  blank  in  consciousness  just  long 
enough  to  do  this. 

On  regaining  consciousness,  which  returned  as  sud- 
denly and  sharply  as  it  disappeared,  and  as  clear  as  it 
was  before  the  attack,  the  patient  was  considerably 
embarrassed  at  what  had  occurred,  recognizing  at 
once  that  she  had  repeatedly  written  the  same  name 
while  in  a  seizure.  This  was  a  typical  attack  of  psychic 
epilepsy. 

R.  F.  H.  had  set  up  and  was  regulating  a  camera 
to  get  a  picture  of  a  map  fastened  to  the  wall.  Two 
hours  before  this  I  had  observed  that  his  face  was 
slightly  flushed,  his  eyes  unusually  bright,  and  that  he 
appeared  animated  and  talkative,  full  of  life,  acting 
very  much  like  a  man  who  had  moderately  indulged 
in  a  stimulant  of  some  kind. 

He  put  his  hand  under  the  cloth  to  look  at  the 
image  on  the  glass,  and,   finding  the  focus  not  just 


2  2  CLASSIFICATION. 

right,  reached  out  his  right  hand  to  move  the  screw- 
that  regulated  it. 

I  was  observing  him  closely,  and  when  I  saw  the 
lens  run  out  and  back  on  the  slideway  some  eight  or 
ten  times  in  rapid  succession,  doing  this  with  his  right 
hand,  and  saw  him  suddenly  grasp  one  leg  of  the 
instrument  with  his  left  hand  and  shake  it  quite  vio- 
lently, I  knew  he  was  having  a  seizure.  Throwing  the 
cover  off  his  head,  I  found  his  eyes  fixed,  slightly  rolled 
upward  and  outward,  the  head  turned  a  little  to  one 
side,  the  jawTs  going  through  rhythmic  masticatory 
movements  with  pronounced  smacking  of  the  lips, 
the  so-called  tasting  movements  that  have  been  referred 
to  as  constituting  an  aura  in  epilepsy. 

He  suddenly  grew  limp  in  the  knees  and  acted  as 
if  he  would  fall  to  the  floor,  when  I  took  hold  of  him 
and  assisted  him  to  a  chair.  He  sat  staring  at  me  in 
a  stupefied,  dazed  sort  of  way  for  possibly  ten  seconds, 
then  got  up  and  walked  out  of  the  room  in  a  most 
natural  way,  and  went  over  to  the  hospital,  about 
two  minutes'  walk;  he  entered  the  dark  room 
which  he  was  accustomed  to  use  for  photographic 
wTork,  immediately  turned,  came  back  to  his  camera, 
and,  in  a  natural  manner,  continued  the  work  of 
taking  the  picture.  This  was  a  typical  convulsion  of 
the  petit  mat  type. 

Both  these  cases  are  illustrations  of  the  forms  repre- 
sented, but  we  frequently  find  one  type  taking  on 
many  of  the  characteristics  of  another,  doing  so  to 
such  an  extent  at  times  that  type  characteristics  are 
almost  completely  destroyed. 

More  than  this,  some  patients  may  have  grand  mat, 
petit  mal,  and  psychic  epilepsy  all  at  the  same  time; 
a  grand  mal  seizure  may  appear  to-day,  a  petit  mal 
to-morrow  or  the  week  after,  while  the  succeeding 
attack  may  be  purely  psychic.  This  fact  is  especially 
well  worth  ■  remembering  when  wre  are  dealing  with 
the  medicolegal  side  of  epilepsy.  I  have  known 
numerous  instances  in  which  attacks  of  one  kind  pre- 
dominated for  several  months  or  a  year,  to  be  followed 


CLASSIFICATION    BASED    ON    ETIOLOGY.  23 

by  attacks  of  an  entirely  different  kind  during  the 
next  year  or  during  a  number  of  months. 

CLASSIFICATION  BASED  ON  ETIOLOGY. 

We  now  come  to  consider  a  classification  based  on 
etiology.  To  formulate  even  a  tentative  one  on  this 
basis  is  a  scientific  problem  of  unusual  magnitude. 

Many  years  of  research  in  the  laboratory  by  a  class 
of  especially  trained  and  qualified  scientists  now 
almost  unknown  because  of  the  meager  opportunities 
offered  for  research  in  this  disease,  combined  with 
additional  years  of  studious  observation  of  the 
clinical  side  of  epilepsy  and  the  epileptic,  must  in- 
tervene before  we  can  construct  an  etiologic  classi- 
fication that  will  meet  the  scientific   demand  for  it. 

I  do  not,  however,  see  any  cause  for  being  dis- 
couraged, for  reflection  will  show  that  students  of 
epilepsy  are  not  as  far  behind  the  students  of  insanity 
in  the  search  for  causes  as  the  casual  observer  might 
at  first  believe ;  notwithstanding  the  fact  that  insanity 
was  a  laboratory  problem  long  before  the  epileptic 
was  cared  for  in  a  way  that  made  his  scientific  and 
clinical  study  in  a  definite  manner  at  all  possible.  And 
then,  again,  epilepsy  and  insanity  *  have  much  in 
common,  especially  so  far  as  psychic  symptomatology 
goes.  Studies  directed  to  the  elucidation  of  etiologic 
problems  in  brain  pathology  in  insanity  must  also 
have  some  measure  of  application  in  the  study  of  the 
epilepsies  along  the  same  line. 

Let  us  briefly  examine  some  points  of  similarity 
between  the  two  diseases. 

We  find,  in  the  first  place,  that  both  diseases  are 
essentially  dependent  upon  the  brain. 

In  the   second  place,   we  know  that  continuously 

*  "Epilepsy  and  insanity,"  says  Gowers,  "certainly  run  together  in 
families.  The  general  tendency  in  one  tends  also  to  involve  the  tendency 
in  the  other,  although  not  often  in  the  same  individual." 


24  CLASSIFICATION. 

normal  brains  give  off,  so  to  speak,  neither  insane  nor 
epileptic  manifestations.  These  are  exceedingly  simple 
propositions,  and  later  on  they  are  used  expressly  to 
illustrate  more  important  points. 

We  also  know  that  insanity  of  almost  every  form, 
whether  it  is  melancholia,  mania,  paranoia,  or  de- 
mentia, or  any  subdivision  of  these,  is  decidedly  more 
apt  to  be  continuous  in  its  manifestations  than  to 
vary  in  any  marked  or  radical  degree.  Whatever  the 
cause  or  causes  of  epilepsy,  the  variations  and  irregu- 
larities that  spring  from  every  form,  phase,  type,  and 
variety  of  the  disease  constitute  one  of  its  most  pro- 
nounced characteristics,  so  that  in  point  of  constancy 
of  symptoms  the  two  diseases  are  widely  unlike. 

All  these  propositions  will  readily  be  granted  as 
true.  But  let  us  remember  that  while  there  is  a 
marked  variation  so  far  as  constancy  of  symptoms  go, 
these  symptoms,  when  they  do  occur,  are  in  many 
respects  identical.  The  maniacal  fury  of  the  epileptic 
in  pre-  or  post-paroxysmal  states,  or  during  the  so- 
called  psychic  epileptic  equivalent,  does  not  differ 
essentially  in  character  from  that  of  ordinary  mania; 
the  incurable  terminal  dementia  of  the  epileptic  does 
not  differ  from  the  terminal  dementia  that  so  fre- 
quently follows  all  forms  of  mental  disease.  In  either 
case  the  disintegrating  and  destroying  action  on  the 
brain  is  identical;  all  of  which  takes  us  back  to  the 
original  starting-point,  namely,  that  so  far  as  the  real 
basis  of  their  manifestations  go,  epilepsy  and  insanity 
have  much  in  common ;  both  spring  from  intermittent 
or  continuous  morbid  cerebral  states  or  disease — ■ 
neither  is  possible  in  any  other  way. 

In  searching  for  a  guide  in  formulating  an  etiologic 
classification,  we  are  impressed  with  the  apparent 
confusion  that  marks  the  incursions  of  scientific  re- 
search into  this  scantily  explored  field  of  medicine  at 
the  present  time. 


CLASSIFICATION    BASED    ON    ETIOLOGY.  25 

There  is  a  notable  lack  of  attempt  at  uniformity 
in  nomenclature  on  the  part  of  such  eminent  authors 
as  Hack  Tuke,  Gowers,  Fere,  Binswanger,  Nothnagel, 
Voisin,  Hughlings- Jackson,  and  others;  and  it  is  of  in- 
terest to  present  the  views  of  some  of  these  to  show 
how  perplexing  and  mystifying  the  subject  is  to  the 
student  who  wants  first  of  all  to  grasp  a  few  elemental 
facts — to  get  hold  of  a  framework  of  established  truths 
about  which  he  can  build  as  simply  or  as  elaborately 
as  he  may  choose. 

From  among  the  thirty-odd  designations  of  epilepsy 
by  Tuke  in  his  most  admirable  "  Dictionary  of  Psycho- 
logical Medicine,"*  we  select  the  following: 

Abortive  Epilepsy. — A  seizure  which  does  not  proceed 
to  loss  of  consciousness. 

Acute  Epilepsy. — A  term  applied  to  eclamptic  con- 
vulsions. 

Alcoholic  Epilepsy. — Convulsions  due  to  alcohol, 
directly  or  indirectly. 

Auditory  Epilepsy. — A  form  of  epilepsy  due  to  disease 
of  the  middle  ear. 

Cortical  Epilepsy. — A  synonym  of  Jacksonian  epilepsy. 

Diurnal  Epilepsy. — In  which  the  fits  occur  in  the 
daytime. 

Gastric  Epilepsy. — Arising  from  some  irritations  in  the 
alimentary  canal. 

Hemiplegic  Epilepsy. — Generally  of  syphilitic  origin, 
in  which  half  of  the  body  or  one  limb  only  is 
convulsed. 

Hysterical  Epilepsy. — The  same  as  hystero-epilepsy. 

Idiopathic  Epilepsy. — The  ordinary  form  of  epilepsy 
in  which  no  organic  cerebral  lesion  is  found  after 
death. 

Acute  Infantile  Epilepsy. — A  synonym  of  infantile 
convulsions. 

Intestinal  Epilepsy. — An  old  term  for  infantile  con- 
vulsions, depending  on  irritating  matters  in  the 
intestines. 

Jacksonian  Epilepsy. — Attacks  of  an  epileptic  charac- 
ter, confined  to  one  leg,  one  arm,  or  a  group  of 
muscles. 

*  Vol.  1,  p.  449,  1892. 


26  CLASSIFICATION. 

Larvated  Epilepsy. — Same  as  masked  epilepsy. 

Maniacal  Epilepsy.— Acute  insanity  due  to  epilepsy. 

Masked  Epilepsy. — An  English  term,  corrupted  from 
the  French  (eptlepsie  larvee)  and  applied  in  cases 
in  which  there  is  only  partial  loss  of  consciousness. 

Matutinal  Epilepsy. — Epilepsy  in  which  the  seizures 
take  place  only  in  the  early  morning. 

Mental  Epilepsy. — The  same  as  masked  or  psychic 
epilepsy. 

Nocturnal  Epilepsy. — In  which  the  fits  occur  only 
during  the  night. 

Partial  Epilepsy. — In  which  the  seizures  are  confined 
to  a  part  of  the  body  only. 

Psychic  Epilepsy. — Periodic  occurrence  of  psychic  dis- 
turbance, or  sensory  illusions,  without  muscular 
involvement. 

Reflex  Epilepsy. — Epilepsy  resulting  from  reflex  irrita- 
tion of  nerves ;  as,  for  example,  neuromata ;  cica- 
trices; tumors  that  involve  peripheral  nerves; 
intestinal  worms ;  ovarian  or  uterine  irritation. 

Spinal  Epilepsy. — A  term  proposed  by  Marshall  Hall 
for  the  grand  mal  or  complete  form  of  epilepsy, 
in  which  sphagiasmus,  odaxismus,  and  laryngis- 
mus succeed  each  other  in  regular  order. 

Provoked  Spinal  Epilepsy. — A  term  for  the  condition 
known  as  ankle  reflex. 

Symptomatic  Epilepsy. — Epilepsy  caused  by  or  a 
symptom  of  some  other  disease. 

Syphilitic  Epilepsy. — Epilepsy  due  to  syphilitic  infec- 
tion, inherited  or  acquired. 

Thalamic  Epilepsy. — A  form  of  epilepsy  supposed  to 
be  due  to  a  lesion  in  the  optic  thalamus.  Special 
sense  aurse  are  supposed  to  oftenest  occupy  this 
form. 

Traumatic  Epilepsy. — Epilepsy  due  to  an  injury  to 
the  brain,  whether  the  lesion  is  a  coarse  one  or 
not. 

Vasomotor  Epilepsy. — A  type  of  epilepsy  in  which  the 
course  is  supposed  to  be  due  to  some  implication 
of  the'  vasomotor  centers,  without  affecting  the 
brain,  muscular  spasms  being  absent. 

I  am  aware  that  the  foregoing  was  not  written  as 
a  distinct  classification,  but  rather  for  the  purpose  of 


CLASSIFICATION    BASED    ON    ETIOLOGY.  27 

defining;  but  while  it  defines,  it  specifies  at  the  same 
time  the  cause  in  numerous  instances,  such  as  alcoholic 
epilepsy,  gastric  epilepsy,  auditory  epilepsy,  renal 
epilepsy,  intestinal  epilepsy,  etc.,  and  being  alphabetic- 
ally arranged,  might  erroneously  be  held  to  include 
a  full  list  of  causes  so  far  as  they  are  known. 

I  can  also  see  much  in  it  that  would  greatly  puzzle 
the  student  of  epilepsy,  in  the  use  of  different  terms 
to  express  the  same  set  of  conditions ;  as,  for  instance, 
when  abortive  epilepsy  is  stated  to  mean  ' '  an  epileptic 
seizure  which  does  not  proceed  to  a  loss  of  conscious- 
ness." This  is  naturally  enough  confounded  with 
Jacksonian  epilepsy,  for  here  the  complete  loss  of 
consciousness  is  not  the  rule.  Or,  again,  it  would  be 
easy  to  confuse  the  masked  epilepsy,  mental  epilepsy, 
and  psychic  epilepsy  this  distinguished  author  gives; 
the  one  characteristic  running  through  them  all  being 
a  sudden,  pronounced  change  in  mentality,  or  tem- 
porary loss  of  mind,  without  any  other  symptoms  what- 
ever. 

Gowers  *  presents  no  classification  based  on  etiology. 
One  is  chiefly  impressed  with  the  positiveness  of  his 
views  on  similar  heredity  as  being  the  chief  cause  of 
the  disease,  for  he  goes  so  far  as  to  pointedly  assert: 
"  Epilepsy  is  an  inherited  disease." 

At  the  same  time,  he  also  refers  to  other  causes, 
including  cortical  injury,  reflex  irritations  that  cause 
symptomatic  fits  only  in  the  beginning,  toxic  agencies, 
and  emotional  shock,  studying  each  under  the  pro- 
portionate influence  they  exert  both  as  proximate  and 
remote  factors  in  etiology. 

In  1870  Echeverria  t  wrote  as  follows: 

"  Epilepsy,  like  paralysis,  is  not  a  morbid  entity 
existing  by  itself,  but  a  manifestation  of  manifold 
derangements    disturbing    the    nervous    system    and 

*  "Epilepsy  and  Other  Chronic  Convulsive  Diseases,"  1901. 
f  Echeverria  on  "Epilepsy,"  1870,  p.  10. 


28  CLASSIFICATION. 

giving  rise  to  definite,  inseparate  conditions— imme- 
diate cause  of  the  convulsive  paroxysm — that  remain 
the  same  whatever  be  the  occasional  origin  of  epilepsy. ' ' 
■ '  No  other  malady  exhibits  a  wider  range  in  its 
etiology.  There  is  scarcely  a  disease  deranging  the 
human  frame  in  which  epileptiform  convulsions  might 
not  happen  as  an  accident  or  essential  phenomenon, 
and  it  may  be  safely  set  down  as  a  truth  of  great 
importance  that  the  numerous  conditions  capable  of 
inducing  epilepsy  give  to  each  of  its  species  a  charac- 
teristic impression  that  will  ever  prevent  conforming 
their  individual  symptons  to  any  typical  case,  or  find- 
ing any  specific  cure  for  every  instance  of  the  disease. 
To  establish  the  peculiar  morbid  conditions  influencing 
its  development,  to  discriminate  the  general  from  the 
local  circumstances,  in  order  to  arrive  at  a  rational 
and  successful  treatment,  is  the  fundamental  question 
in  the  study  of  epilepsy." 

It  is  of  interest  to  bring  forward  the  views  of  this 
writer  to  show  that  while  the  widespread  and  protean 
causes  of  epilepsy  were  so  fully  appreciated  a  third 
of  a  century  ago,  nothing  has  yet  been  done  in  the 
way  of  classifying  clinical  types  on  an  etiologic  basis. 
Echeverria  himself  made  no  effort  in  this  direction. 
He  appears  to  have  made  use  chiefly  of  the  terms 
grand  mal  and  petit  mal  in  speaking  of  seizure  types, 
giving  accounts  of  these  in  connection  with  Marshall 
Hall's  so-called  spinal  system. 

Nothnagel  makes  use  of  the  following  simple  classi- 
fication : 

i.  "Epilepsies  in  which  the  classical  paroxysms 
make  their  appearance  with  coma  and  general  con- 
vulsions.     (E.  Gravior,  haut  mal.) 

2.  "Epilepsies  in  which  paroxysmal  loss  of  con- 
sciousness alone  occurs,  the  spastic  element  for  the 
voluntary  .muscles  at  all  events  being  absent.  (E. 
Mitior-,  petit  mal.) 

3.  "Epilepsy  in  which,  with  inconsiderable  loss  of 
consciousness,  partial  twitchings  occur  in  regions  of 
certain  muscles,  whereby  in  the  most  various  ways 


CLASSIFICATION    BASED    ON    ETIOLOGY.  29 

a  transition  is  effected  between  the  cases  mentioned 
under  i  and  2. 

4.  "To  these  we  add  the  irregular  forms  of  seizures 
and  the  epileptoid  states." 

Turning  to  the  French  writers,  in  the  very  excellent 
works  of  Fere  and  Voisin  but  little  is  to  be  found  in  the 
way  of  classification  founded  on  etiology.  Indeed,  the 
Definitions  offered  by  Fere,  while  failing  to  convey  to 
the  student  much  information  as  to  what  epilepsy  is, 
show  very  comprehensively  how  wide  a  range  of 
pathologic  conditions  must  underlie  its  many  forms. 

Fere  says :  "Asa  matter  of  fact,  we  must  look  upon 
epilepsy  as  a  group  of  symptoms  which  may  appear 
in  greater  or  lesser  number  in  the  course  of  very 
different  pathologic  conditions,  sometimes  under  one 
form,  sometimes  under  another.  To  say  that  there  is 
only  one  true,  essential  epilepsy  which  occurs  without 
appreciable  cause,  seems  to  me  to  be  no  more  admissi- 
ble than  to  claim  that  there  is  only  one  true  angina 
pectoris,  which  has  for  its  cause  the  contraction  of 
the  coronary  arteries  and  false  anginas  of  toxic,  hys- 
terical, and  other  origin.  Epilepsy  applies  solely  as 
a  symptom-complex  and  may  be  general  or  partial." 

In  the  above  quotations  there  is  a  truth  so  sound,  so 
full  of  scientific  accuracy,  and  so  worthy  of  universal 
recognition  that  I  venture  to  repeat  them  in  sub- 
stance that  they  may  make  a  more  lasting  impression. 

"  Epilepsy  is  not  a  morbid  entity,  "  says  Echeverria. 

"Epilepsy  is  a  group  of  symptoms,  due  to  different 
pathological  conditions,"  says  Fere. 

These,  it  is  true,  do  not  help  per  se  in  our  search  for 
a  classification  founded  on  etiology,  but  they  do  show 
that  the  causes  are  numerous  and  that  any  classification 
on  this  basis  must  recognize  part,  if  not  all,  of  them. 

The  designations  of  the  different  forms  of  epilepsy 
offered  by  Voisin  are  no  more  systematically  arranged 
in  their  causal  relationship  than  are  those  of  other 
distinguished  writers. 


3° 


CLASSIFICATION. 


It  is  scarcely  worth  while  to  pursue  this  phase  of  the 
subject  further.  Enough  has  been  said  to  show  that 
the  time  is  not  yet  ripe  for  a  satisfactory  etiologic 
classification,  as  the  causes  of  epilepsy  are  so  numer- 
ous and  so  varied.  For  the  present,  the  best  etiologic 
classification  must  be  based  on  causes  in  the  order 
of  their  importance,  and  which  are  now  generally  ac- 
cepted as  underlying  the  different  forms  of  the  dis- 
ease. In  doing  this,  mention  must  be  made  of  two 
facts  which  stand  out  more  prominently  than  all  the 
rest,  namely: 

i .  That  epilepsy  is  a  condition  or  disease  dependent 
on  nervous  or  degenerative  disease  in  the  parent  more 
frequently  than  on  any  other  single  cause. 

2.  That  fully  80  per  cent,  or  more  of  all  cases  of 
epilepsy  begin  before  the  twentieth  year. 

These  two  facts,  which  bear  the  prestige  of  well- 
nigh  universal  recognition,  form  the  basis  of  a  prac- 
tical classification  for  present  use. 

GROUP  I. 

Embracing  the  Epilepsies  most  Common  to  the  Infantile  Period,  beginning 
at  Birth  and  Ending  with  the  Third  Year* 

Under  this  head  are  included 
cases  in  which  the  fundamental 
elements  of  epilepsy  itself  were 
handed  down  from  parent  to 
child — direct  inheritance — as 
distinguished  from  indirect  in- 
heritance, in  which  epilepsy  in 
the  child  is  due  to  some  other 
disease  than  epilepsy  in  the 
parent,  such  as  alcoholism  or 
insanity. 

Under  this  are  included  all  cases 
in  which  epilepsy  is  due  in  the 
main  to  such  diseases  as  alco- 
holism and  insanity  in  the 
parent;  and  in  which  there  is 
transmitted  to  the  child  a 
general  instead  of  a  specific 
tendency  to  a  particular  dis- 
ease. 

*  The  fixing  of  this  and  other  age  periods  is  more  or  less  arbitrary,  as 
we  shall  see  later  on  when  we  come  to  study  the  ages  at  which  definite 
epilepsies  are  apt  to  develop  under  the  stimulus  of  certain  causes.  The 
practical  importance  of  the  age-grouping  scheme  is  its  chief  recommendation. 


Infantile  Inherited 
Epilepsy. 


Similar 
Heredity. 


Dissimilar 
Heredity. 


CLASSIFICATION    BASED    ON    ETIOLOGY. 


31 


Infantile  Accidental 
Epilepsy. 


The  origin  of  epilepsy  under  the  causes  above  are 
due  in  the  majority  of  cases  to  some  exciting  cause 
which  close  study  may  reveal,  while  in  other  cases  the 
epilepsy  comes  on  in  strongly  predisposed  children 
without  any  exciting  cause  that  we  can  discover. 

Including  pre-natal  causes,  such  as  inherited 
syphilis,  birth  accidents,  asphyxiation,  and  in- 
juries from  forceps;  the  specific  fevers,  such 
as  scarlet  fever  and  whooping-cough;  the  con- 
vulsions of  dentition  in  suitable  cases;  emo- 
tional shock  due  to  fright,  and  cerebral  palsy. 

In  these  cases  hereditary  influences  may  or  may  not 
assist  in  producing  the  convulsions,  the  immediate  or 
exciting  causes  being  in  themselves  qualified  to  bring 
on  the  attacks. 

Including  cases  due  to  mechanical  injuries  in- 
flicted on  the  surface  of  the  body  in  a  manner 
to  affect  the  integrity  of  vital  internal  func- 
tions, mostly  in  the  form  of  injuries  to  the 
brain,  and  possibly  to  injuries  of  peripheral 
nerves  causing  reflex  convulsions  in  the  be- 
ginning. 

Including  all  cases  in  which,  after  careful  and 
repeated  examination,  we  fail  to  find  any  of 
the  causes  named  in  the  three  forms  above. 


Infantile  Traumatic 
Epilepsy. 


Infantile  Idiopathic 
Epilepsy. 


We  may  ascribe  the  origin  of  some  cases  under  this 
head  to  heredity,  if  such  influences  can  be  found ; 
while  others  must  stand  as  idiopathic  epilepsy  alone. 

GROUP  II. 

Embracing  the  Causes  of  Epilepsies  Common  to  Childhood  and  the  Early  Life 

Period,  beginning  with  the  Fourth  Year  and  Ending  at 

about  the  Twentieth  Year. 

Embracing  all  cases  in  which  the  disease  is 
due  to  the  infectious  fevers,  such  as 
scarlet  fever;  to  peripheral  irritations  of 
various  kinds  that  excite  and  eventually 
produce  habit  epilepsy;  to  emotional  shock 
and  to  cerebral  palsy. 

Embracing  all  cases  in  which  epilepsy  is 
the  direct  result  of  a  mechanical  injur}-  to 
the  brain. 

Embracing  cases  in  which  the  stress  of 
puberty,  acting  on  a  weakened  organism, 
brings  to  light  the  nervous  disorder  to 
which  the  individual  is  predisposed. 
Cases  of  delayed  heredity  fall  under  this 
head  in  a  good  many  instances,  the  stress 
of  the  period  serving  as  the  exciting  cause. 


Accidental  Epilepsy.  . 


Traumatic  Epilepsy 


Developmental  Epilepsy  • 


32 


CLASSIFICATION. 


Idiopathic  Epilepsy  . 


Embracing  all  cases  in  which,  after  careful, 
repeated  examinations,  we  fail  to  find  any 
cause,  proximate  or  remote,  inherited  or  ac- 
quired, sufficient  in  kind  or  degree  to 
bring;  on  the  attack.* 


Accidental  Epilepsy. 


group  ni. 

Embraces  all  Epilepsies  in  -which  there  were  no  Convulsions  Prior  to  the 
Twentieth  Year,  and  which  Occur  from  any  Cause  after  that  Period. 

Embraces  all  cases  of  syphilitic  infection; 
all  cases  of  peripheral  irritation;  cases 
due  to  the  infectious  fevers;  and  those  due 
to  ovarian  or  uterine  irritations  of  all 
kinds  and  degrees,  the  latter  at  first  pro- 
ducing reflex  convulsions  only,  but  which, 
if  unchecked,  may  degenerate  into  a 
severer  form  of  the  disease. 

The  toxic  causes  embrace  alcohol,  which  is 
more  prominent  than  all  the  rest  com- 
bined in  this  group;  the  intestinal  tox- 
emias; poisoning  from  lead  (a  form  of 
exceeding  rarity))  and  all  others  due  to 
chemical  poisoning  of  any  kind. 


Toxic  Epilepsies 


It  may  appear  inconsistent  to  place  syphilitic  infec- 
tion among  the  accidental  causes  and  alcoholic  poison- 
ing among  those  due  to  toxic  causes,  but  this  is  done 
because  the  latter  is  more  a  disease  due  to  design  than 
to  accident,  drinking  itself  being  the  essential  act  that 
creates  the  epilepsy. 

[  Embracing  cases  in  which  epilepsy  is  the 
direct  result  of  any  mechanical  injury  to 
the  brain.  This  form  of  cause  is  the  same 
through  all  the  age  periods. 

Embracing  all  cases  in  which,  after  careful, 
repeated  examinations,  we  fail  to  find  any 
cause,  proximate  or  remote,  inherited  or 
acquired,  sufficient  in  degree  or  kind  to 
bring  on  the  disease. 

Embraces  all  epilepsies  due  to  senile  changes, 
mostly  to  those  in  the  vascular  system, 
which  become  prominent  any  time  after 
the  fortieth  year,  though  not  usually  until 
the  sixtieth  or  after.  This  class  might 
properly  be  included  with  those  due  to 
accidental  causes,  but  is  sufficiently  dis- 
tinctive to  class  it  alone. 

*  The  question  might  properly  be  raised  as  to  why  many  of  the  convul- 
sions of  early  life  should  not  be  classed  as  eclamptic.  Undoubtedly  they 
should  be  at  first.  We  follow  Gowers  ("The  Infantile  Causes  of  Epilepsy," 
"Clinical  Lectures,"  p.  205)  in  here  including  cases  in  which  eclamptic 
convulsions  later  passed  into  true  epilepsy. 


Traumatic  Epilepsy 


Idiopathic  Epilepsy 


Senile  Epilepsy 


Plate  i, 


Senile  Epilepsy. 
Epilepsy  due  to  senile  changes,  particularly  arteriosclerosis,  is  not 
infrequently  met  with  after  the  forty-fifth  to  fiftieth  years  and  more  fre- 
quently after  the  sixtieth  year.  The  first  typical  grand  mal  convulsion 
occurred  in  Z.  R.  at  eighty-nine  years.  Similar  attacks  continued  at  in- 
tervals of  a  few  weeks  until  his  death  when  he  was  nearly  ninety-three. 
He  had  a  marked  general  atheromatous  condition,  noted  on  autopsy,  and 
was  subject  to  infrequent  periods  of  mild  psychic  disturbance  that  lasted 
from  two  to  three  days.  He  suffered  no  permanent  mental  impairment, 
had  a  remarkable  memory,  and  exhibited  none  of  the  stigmata  so  often 
noted  in  subjects  of  essential  epilepsy. 


EXAMINATION    SCHEME    OUTLINED.  33 

We  might  now  take  up  each  of  the  foregoing  heads, 
divide  and  subdivide  the  causes  that  make  up  each; 
but  that  would  only  tend  to  greater  confusion,  in 
addition  to  creating  a  drift  toward  a  special  name  for 
the  epilepsy  that  follows  each  specific  cause.  As  it  is 
now,  it  includes  the  principle  of  the  cause  only,  not  all 
its  manifestations. 


METHOD  OF  EXAMINING  FOR  EPILEPSY. 

It  is  comparatively  rare  for  the  average  student  or 
physician  to  witness  any  considerable  number  of 
epileptic  convulsions  in  their  entirety ;  that  is,  to  see  the 
prodromal,  the  active  convulsive  stage,  the  end  of  the 
fit,  and  to  study  its  effects  on  the  patient  immediately 
after,  and  during  the  inter-paroxysmal  period,  which 
may  be  of  a  few  minutes'  or  of  several  months'  dura- 
tion. 

It  is  the  diagnosis  of  the  type  of  the  convulsion  itself, 
however,  that  is  of  the  most  importance.  The  outlined 
examination  scheme  that  follows  is  based  on  this  fact. 
Other  aids  to  diagnosis  are  fully  considered  in  the 
chapter  under  that  heading. 

EXAMINATION  SCHEME  OUTLINED. 
The  examination  of  every  case  may  be  divided  into 
four  parts  as  follows : 

1.  The  family  history. 

2.  The  personal  history. 

3.  The  history  of  the  epilepsy. 

4.  The  personal  examination  of  the  patient. 

The  fact  that  epilepsy  is  so  often  an  inherited  dis- 
ease makes  systematic  inquiry  into  the  family  history 
important,  and  this  inquiry  to  be  of  the  greatest  value 
should  be  conducted  under  an  orderly  arrangement  of 
questions  similar  to  the  following,  which  is  transcribed 
in  part  from  the  official  records  in  use  at  the  Craig 


34  METHOD    OF    EXAMINING    FOR    EPILEPSY. 

Colony,  and  modified  to  better  meet  the  requirements 
of  the  general  practitioner. 

The  Patient's  Family  History. 

i.  Father:     Living    or    dead?     Age?     If    dead,    as- 
certain the  age  at  death,  and  the  cause  of  death. 

2.  Mother:     Living    or    dead?     Age?     If    dead,    as- 

certain the  age  at  death,  and  the  cause  of  death. 

3.  Father's   father:    Age?     If   dead,   state   age   and 

cause. 
Father's  mother:    Age?     If  dead,  state  age  and 
cause. 

4.  Mother's  father:    Age?     If  dead,   state   age   and 

cause. 
Mother's  mother:    Age?     If  dead,  state  age  and 
cause. 

5.  Number  of  children  in  the  family:    Boys;    girls; 

the  patient's  number  in  line  of  birth. 
Number  of  children:   Living?     Dead? 

6.  Did    the    patient's     brother,    sisters,    father,    or 

mother  ever  have  epilepsy?  "Spasms"? 
"Fainting  spells"?  Nervous  prostration? 
Hysteria?  Insanity?  If  so,  at  what  age,  in 
what  way,  and  how  long  did  it  last  ? 

7.  Have  any  uncles  or  aunts  or  other  near  relatives 

ever  had  any  of  the  above  diseases  or  any  other 
form  of  nervous  disease?  If  so,  state  which 
relative  and  describe  the  condition. 

8.  Was  the  patient's  father  or  mother  ever  given  to 

intemperance,  and  to  what  extent? 

9.  Have  either  ever  suffered  from  severe  headaches 

at  fixed  times? 

10.  Did  the  father  or  mother  ever  have  rheumatism, 

tuberculosis,  scrofula,  syphilis,  or  blood-poison- 
ing of  any  kind? 

11.  Was   there   epilepsy,    or   insanity,    or   any   other 

nervous  diseases  in  the  grandparents? 

The  Patient's  Personal  History. 

1.  Date  of  birth:  Year.     Month.     Present  age. 

2.  Was  the  patient  born  at  full  term?     If  premature 

delivery,  state  at  what  month  and  all  facts 
regarding  the  same? 


EXAMINATION    SCHEME    OUTLINED.  35 

3.  Was  labor  normal  in  duration? 

4.  Was  delivery  natural  or  instrumental? 

5.  Was  the  patient  injured  in  any  manner  during 

delivery  ? 

6.  Was  the  mother  injured  or  frightened  previous  to 

the  birth  of  the  child? 

7.  Weight  of  the  patient  at  birth?     Was  the  baby 

strong  or  ' '  puny ' '  ? 

8.  Did  the  patient  have   "spasms"   or  convulsions 

immediately  after  birth? 

9.  Was  the  patient  paralyzed  in  any  way  at  or  im- 

mediately after  birth? 

10.  Was  the  patient    nursed  by  the    mother  or  fed 

artificially  ? 

11.  Was  the  patient,  as  a  baby,  subject  to  "indiges- 

tion," "pain  in  the  stomach,"  or  prolonged 
"fits"  of  crying? 

12.  At   what   age   did   teething   commence?     Was   it 

difficult,  and  how? 

13.  Did  the  patient  have  any  "spasms"  or  "convul- 

sions" during  teething? 

14.  Did  the  patient  have  fits  of  crying  during  the  night, 

or  "start  in  its  sleep,"  or  have  "night  terrors" 
during  infancy  or  early  childhood  ? 

15.  At  what  age  did  the  patient  commence  to  walk? 

16.  Did  the  patient  have  any  difficulty  in  learning  to 

walk,  or  show  any  evidence  of  being  weak  in 
one  leg,  or  of  being  paralyzed? 

17.  Did  the  patient  show  any  evidence  of  "rickets" 

or  of  "scrofula"? 

18.  Was  the  patient  given  cod-liver  oil  or  tonics  as 

a  child? 

19.  Did  the  patient  suffer  from  swollen  glands  about 

the  neck? 

20.  Did  the  patient  ever  suffer  from  frequent  attacks 

of  "nose-bleed"  coming  on  without  any  ap- 
parent cause? 

21.  Did  the  patient  have   an  accident  or  injury  of 

any  kind,  especially  about  the  head,  in  infancy 
or  early  life?  Was  it  ever  necessary  for  an 
operation  of  any  kind  to  be  performed  ? 

22.  Ascertain  if  the  patient  had  any  of  these  diseases 

and  whether  they  left  any   ' '  mark ' ' :    Scarlet 


36  METHOD    OF    EXAMINING    FOR    EPILEPSY. 

Fever?     At    age    of    .     Measles?     At    age 

of    .       Diphtheria?       At     age     of    . 

Whooping-cough?  At  age  of  .  Menin- 
gitis?    At  age  of  . 

History  of  the  Patient's  Epilepsy. 

1 .  At  what  age  did  the  patient  have  first  convulsions 

or  epileptic  seizures? 

2.  Have  them  described  as  fully  as  possible  by  the 

person  who  witnessed  them,  if  that  can  be  done. 

3.  Ascertain  the  supposed  cause  of  the  first  attack. 

4.  How  soon  after  the  first  attack  did  the  second 

occur? 

5.  What  was  supposed  to  be  the  cause  of  the  second 

attack? 

6.  Find  out  how  often  the  attacks  have  occurred 

during  the  past  two  or  three  years,  and  whether 
they  have  changed  any  since  the  first  attack, 
and  if  so,  in  what  way. 

7.  Get  a  description  of  the  last  attack,  as  full  as  pos- 

sible. 

8.  Does  the  patient  have  a  "warning"  of  any  kind 

that  an  attack  is  coming?  If  so,  ascertain  its 
nature  and  constancy. 

9.  Does  the  patient  have  more  than  one  kind  of  at- 

tack (that  is,  severe  and  mild  attacks)  ?  If  so, 
get  a  description  of  each. 

10.  Find  out  which  arm  or  leg,  or  side  of  the  face,  or 

other  part  of  the  body,  is  first  and  most  often 
affected,  and  whether  consciousness  is  appar- 
ently lost  at  each  attack. 

1 1 .  Ascertain  if  the  patient  remembers  what  took  place 

during  the  attack,  and  how  long  after  it  is  over 
before  he  is  able  to  resume  work  engaged  in 
before  the  attack  came  on. 

12.  Has  the  patient  ever  received  any  serious  injury, 

burn,  fall,  fracture,  or  dislocation  during  an 
attack  ? 

13.  Is  there  "false  sight"  or  "false  hearing"  at  any 

time,  especially  just  before  or  after  a  convulsion  ? 

14.  How  has  the  patient's  memory  been  affected  by 

the  disease,  and  has  there  been  a  change  in  dis- 
position.    Is  there  much  irritability? 


EXAMINATION    SCHEME    OUTLINED.  37 

15.  Has  there  ever  been  any  paralysis  of  any  kind 

following  seizures?  If  so,  was  the  patient 
seriously  ill  at  the  time  the  paralysis  appeared 
or  was  first  noticed,  and  what  was  the  nature 
of  the  paralysis?  Has  it  become  better  or 
worse  since  first  noticed? 

16.  Has    there    ever    been   loss    of    speech    following 

seizures  ? 

17.  What  is  the  greatest  number  of  seizures  or  "  spells  " 

the  patient  has  had  in  twenty-four  hours  ? 

18.  Were  these  seizures  or  "spells"  all  alike?     If  not, 

how  did  they  differ? 

19.  Does  the  patient  ever  have  a  large  number  of 

attacks  in  one  or  two  days  accompanied  by 
high  fever  and  marked  prostration? 

20.  How  often   does  the   patient  have   a   "series   of 

attacks ' '  ? 

2 1 .  When  did  such  a  series  occur  last  ? 

22.  Is  the  patient  getting  better  or  worse,  and  why? 

23.  What  form  of  treatment  has  the  patient  received? 

24.  Is  there  any  defect  of  sight,  or  hearing,  or  speech? 

25.  Is  there  any  tendency  toward  gluttony,   or  un- 

natural appetite  for  any  particular  article  of 
food  or  drink? 

26.  Does  the  patient  sleep  well? 

27.  Does  the  patient  show  any  tendency  to  destroy 

things,  or  to  injure  himself  or  others? 

28.  Is  the  patient  obedient  and  does  he  respect  the 

authority  of  those  who  look  after  him? 

29.  Can  the  patient  read  and  write,  and  does  he  possess 

special  aptitude  for  any  particular  line  of 
occupation,  such  as  music,  drawing,  arith- 
metic, etc.  ? 

30.  Is  the  patient  especially  uncontrollable  before  or 

during  seizures  ? 

31.  Is  the  patient  cleanly  in  habits  and  tidy  in  dress? 

32.  Has  the  patient  any  vicious  habits? 

If  we  can  get  satisfactory  answers  to  the  foregoing 
questions,  we  will  be  able  to  form  a  very  fair  estimate 
of  the  case,  though  to  base  a  diagnosis  and  outline  a 
plan  of  treatment  on  this  alone,  would  be  unjust  to 
the  patient  and  an  unscientific  procedure  on  the  part 


38  METHOD    OF    EXAMINING    FOR    EPILEPSY. 

of  the  physician,  for  nothing  can  give  so  complete 
information  as  a  thorough  personal  examination, 
repeated  as  often  as  necessity  demands. 

Confirmed  epileptics  often  have  a  nomenclature  of 
their  own.  Some  who  would  not  know  the  meaning 
of  a  seizure,  know  of  "spells";  others  have  only 
"fits,"  others  "convulsions,"  "weaknesses,"  "dizzy 
spells,"  "turns,"  etc.  This  should  be  borne  in  mind 
in  history-taking. 

THE  PERSONAL  EXAMINATION. 

The  Physiognomy  of  the  Patient. — We  can  sometimes 
make  a  tolerably  certain  diagnosis  of  epilepsy  from 
inspection  of  the  patient  alone,  two  pronounced  facial 
conditions  making  this  possible :  one,  which  is  the  far 
more  common,  the  unsightly  eruption  due  to  excessive 
bromid  intoxication;  the  other,  the  existence  on  some 
prominent  part  of  the  face  or  head,  such  as  the  point 
of  the  chin,  the  supraorbital  ridge,  or  the  occiput,  of 
a  segregation  of  scars  caused  by  repeated  falls  by 
which  the  same  place  is  injured  each  time. 

The  bromic  acne  is  a  less  sure  guide  than  the  scars, 
for  very  similar  eruptions  may  be  due  to  other  causes. 
These  are  especially  apt  to  occur  in  favorable  subjects 
about  the  age  of  puberty. 

The  fades  epileptica  of  which  we  are  accustomed  to 
hear,  is  of  exceeding  rarity  if  it  is  held  to  include 
facial  expressions  or  conditions  to  be  regarded  as 
pathognomonic  of  epilepsy. 

The  only  class  of  cases  to  which  it  should  be  un- 
failingly applied  would  be  those  of  the  grand  mal  type, 
in  which  the  convulsions  throw  the  patient  or  cause 
him  to  fall  in  such  a  manner  as  to  strike  the  same 
part  of  the. body  each  time,  eventually  producing  a 
mass  of  scar  tissue  in  which  it  is  possible  to  distinguish 
repeated  injuries.  This,  combined  with  a  large  degree 
of  mental  impairment,   and  a  profuse  bromic   acne, 


THE    PERSONAL    EXAMINATION.  39 

make  up  the  only  true  fades  epileptica.  These  stig- 
mata of  the  disease  are,  in  part  at  least,  being  rapidly 
destroyed  by  modern  scientific  treatment. 

The  illustrations  presented  (Plates  13,  14,  15,  16,  17, 
19,  and  20)  show  these  conditions  very  clearly. 

The  mental  condition  should  be  carefully  studied  in 
every  case,  for  much  may  be  learned  from  this  alone 
as  to  the  type  and  frequency  of  the  disease. 

In  comparatively  recent  cases  in  which  the  epilepsy 
is  due  to  organic  disease,  the  effects  on  the  mind  may 
be  very  slight,  and  any  pronounced  impairment  may 
be  postponed  for  years,  and  in  rare  instances  never 
appear  in  a  way  to  attract  the  especial  attention  of 
the  patient  or  of  his  friends. 

In  other  cases,  in  which  the  cause  is  largely  hereditary , 
or  the  disease  is  idiopathic,  and  in  which  the  convul- 
sions began  very  early  in  life,  rapidly  and  progressively 
growing  worse,  the  mind  may  be  entirely  destroyed  in 
two  or  three  years,  or  even  in  less  time. 

The  effects  of  epilepsy  on  the  mind  may  be  classified 
under  five  heads : 

In  the  first  the  effect  is  substantially  nil,  the  patient's 
mental  condition  being  good,  save  momentarily  during 
a  mild  seizure. 

In  the  second  a  slight  impairment,  usually  a  loss  of 
memory,  is  observed;  the  mental  condition  in  these 
cases  being  fair. 

In  the  third  the  degree  of  mental  impairment  has 
progressed  a  step  further,  affecting  the  patient's  judg- 
ment, personal  ambition,  and  volition,  the  patient  here 
being  feeble-minded. 

In  the  fourth  there  is  a  still  more  pronounced  con- 
dition of  infirmity,  the  patient  being  robbed  of  nearly 
all  brain  power.  He  is  still  able  to  look  after  his 
bodily  wants,  as  a  rule;  although  in  some  cases  this 
power,  too,  is  impaired  or  destroyed.  These  are  cases 
of  imbecility. 


40  METHOD    OF    EXAMINING    FOR  EPILEPSY. 

In  the  fifth  there  is  total  lack  of  brain  and  body 
power.  The  loss  of  mental  integrity  is  complete. 
This  form,  epileptic  dementia,  is  the  lowest  condition 
of  all,  save  the  lowest  types  of  epileptic  idiocy. 

Memory,  without  exception,  is  the  first  faculty  of 
the  mind  to  sutler.  Fully  90  per  cent,  of  all  the  patients 
that  have  ever  come  under  the  writer's  observation 
evidenced  some  loss  of  memory.  Many  cannot  remem- 
ber recent  events,  although  they  can  distinctly  recall 
things  that  happened  before  they  had  the  disease, 
even  as  far  back  as  thirty  or  forty  years.  Recent 
attacks  seem  to  disorganize  and  destroy  the  impression 
of  recent  events  without  affecting  the  memory  of 
things  learned  long  ago. 

Unless  we  are  careful  we  may  sometimes  be  led  into 
the  error  of  mistaking  the  effects  of  long-continued 
use  of  the  bromids  for  essential  mental  impairment 
due  to  the  disease.  The  point  of  differentiation  is  the 
restoration  of  the  mental  faculties  on  the  withdrawal 
of  the  bromids. 

A  number  of  instances  of  temporary  mental  aberra- 
tion, closely  resembling  primary  dementia,  and  due 
solely  to  the  excessive  and  unguarded  use  of  the 
bromid  salts,  have  come  under  my  notice  during  the 
past  fifteen  years.     In  two  cases  death  was  the  result. 

THE  PHYSICAL  EXAMINATION. 

No  lesion  in  an  epileptic,  or  in  a  person  suffering 
from  epileptiform  convulsions,  is  too  slight  to  be 
looked  for,  and  it  is  of  the  utmost  importance  that  a 
thorough  physical  examination  should  be  made  in 
every  case.  It  is  unnecessary  to  describe  here  the 
various  instruments  of  precision  required  for  the  pur- 
pose, since  they  are  the  same  as  those  used  ordinarily 
in  neurologic  diagnosis.  But  mention  will  be  made  of 
what  may  be  found  as  possible  causes  of  the  disease. 

Forms  of  paralysis  are  quite  common  in  epileptic 


THE    PHYSICAL    EXAMINATION.  41 

subjects,  but  they  are  not  always  conspicuous.  The 
apparent  absence  of  lameness  or  other  disorders  of 
motility,  in  any  part  of  the  body  should  not  warrant 
the  neglect  of  stripping  the  patient  and  carefully 
examining  the  whole  body,  measuring  the  muscular 
force,  noting  the  circumference  of  the  legs  and  arms, 
testing  all  the  reflexes,  superficial  and  deep,  in  addition 
to  carefully  examining  the  sight,  hearing,  and  the 
general  sensory  conditions  all  over  the  body,  in  the 
search  for  heightened  or  lessened  sensorial  perceptions 
and  anesthetic  or  hyperesthetic  areas. 

Care  should  be  exercised  not  to  confound  forms  of 
temporary  or  exhaustion  paralysis  due  to  recent  con- 
vulsions with  paralysis  due  to  more  fixed  organic 
causes,  such  as  cerebral  palsy. 

Nutritional  disturbances  are  sometimes  met  with  in 
epilepsy.  In  view  of  the  part  the  toxemias  of  gastric 
and  intestinal  origin  seem  destined  to  play  in  future 
as  contributory  or  specific  causes  in  the  production  of 
certain  forms  of  epilepsy,  they  demand  our  careful 
attention. 

Gluttony  among  certain  epileptics  is  proverbial,  and 
frequently  the  regulation  of  dietetic  habits  is  one  of 
the  first  indications  of  treatment. 

The  heart  and  lungs  during  epileptic  convulsions 
suffer  in  greater  proportion  than  any  of  the  other 
organs,  with  the  single  exception  of  the  brain.  Conse- 
quently it  is  important  to  carefully  examine  the  heart 
and  lungs  in  every  case,  special  inquiry  being  made 
for  tuberculous  tendencies  or  diseases,  for  asthmatic 
affections,  for  angina  pectoris  and  other  diseases  of 
the  heart,  especially  those  of  atheromatous  type, 
which  in  old  persons  sometimes  cause  symptomatic 
epilepsy  of  a  very  distressing  type. 

Other  irritative  lesions  that  may  produce  habit 
epilepsy  are  found  among  the  following:  Tumors,  cen- 
tral and  peripheral,  the  latter  occurring  as  neuromata, 


42  METHOD    OF    EXAMINING    FOR   EPILEPSY. 

the  former  occurring  in  any  form  that  affects  the 
brain;  cicatrices;  foreign  bodies;  reflex  irritation  of 
carious  teeth;  vesical  and  renal  calculi;  nasal  and 
nasopharyngeal  growths;  ocular  defects,  chiefly  of 
astigmatic  type;  helminthes  of  various  kinds;  and 
otitis. 

The  reproductive  organs  call  for  more  than  a  super- 
ficial examination.  First  of  all,  the  urine,  especially 
collected  just  before  and  after  the  seizure  periods, 
should  be  thoroughly  examined,  chemically  and  micro- 
scopically, in  the  search  for  renal  and  bladder  disease, 
and  for  an  increase  in  urinary  deposits  due  to  excessive 
changes  in  metabolism. 

Urethral  strictures,  adherent  prepuce,  ovarian  and 
uterine  irritation,  and  the  various  forms  of  displace- 
ment should  be  carefully  searched  for,  effort  being 
made  to  show  if  there  is  an  excess  of  convulsions  about 
the  menstrual  epoch. 

The  thermometer  is  of  value  in  establishing  epilepsy, 
provided  it  can  be  used  just  before  and,  especially, 
immediately  after  the  attacks,  when  some  elevation 
of  temperature  may  be  noted  in  more  than  half  of 
all  cases.  In  the  chapter  on  Diagnosis  the  use  of 
this  instrument  is  referred  to  in  detail. 

THE  STIGMATA  OF  DEGENERATION. 

The  epileptic  offers  a  wide  field  for  the  study  of  the 
stigmata  of  degeneration.  Under  careful  scrutiny  his 
characteristics  in  this  respect  fully  come  up  to  those 
of  other  defective  classes,  particularly  the  insane. 

"These  stigmata,"  says  Peterson,*  "are  vices  of 
functional  and  organic  evolution.  The  deviation  from 
the  normal  may  be  in  the  way  of  excesses  or  arrest 
of  development.  They  must  be  distinguished  from 
the  deficiencies  or  deformities  produced  by  accident 
at  birth  or  by  disease." 

*  "Mental  Diseases,"  Church  and  Peterson,  p.  613,  1899. 


Plate  2. 


Palate  with  Gothic  arch  (Peterson). 


The  hip-roofed  palate  (Peterson). 


THE    PHYSICAL    EXAMINATION. 


43 


Peterson  presents  an  elaborate  classification  of  the 
various  degenerative  indices,  to  which  the  reader  is 


Fig.  i. — Chemocephalus  or  flat-headedness. 


Fig.  2. — Oxycephalus  or  steeple-shaped  skull. 


Fig.  3.— Plagioce- 
phlus  or  obalique  de- 
formity of  the  head. 


VerTe 


VerVet 


ANTEROPOSTERIOR 


CIRCUMFERENCE 


:5Mr Left) 


TRANSVERSE 


Fig.  4. — Microcephalic  contours. 


Fig.  5. — Hydrocephalic  contours. 


referred  for  more  complete  information  on  the  subject. 
This  classification  is  under  three  heads,  and  in  sub- 
stance is  as  follows : 


44 


METHOD    OF    EXAMINING    FOR    EPILEPSY. 


Anatomic  Stigmata. 

Cranial  anomalies. 

Facial  asymmetry. 

Deformities  of  the  palate. 

Anomalies  of  the  teeth. 

Anomalies  of  the  tongue  and  lips. 

Anomalies  of  the  nose,  eyes,  ears,  and  limbs. 


Fossa  ovalis. 


Fossa  cymba;. 


Fossa  concha. 


Incisura  intertragica. 


Fossa  scaphoidea. 


Fig.  6. — Normal  ear. 


Fig.  7.- — Excessive  length  of  ear; 
fusion  and  distortion  of  helix,  an- 
thelix,  antitragus,  and  lobule  (Peter- 
son). 


Fig.  S — Triplication  of  crura 
furcata;  malformed  helix  and  an- 
titragus; absent  lobule  (Peterson). 


Various  body  malformations. 
Anomalies  of  the  skin  and  hair. 
Physiologic  Stigmata. 

Anomalies  of  motion : 
Tics,  tremors,  etc. 


Plate  3. 


Low  grade  imbecile  epileptic,  shelving  "Morel"  ears  marked  by  abnormal 
development  of  the  helix,  antihelix,  fossa  scaphoidea,  and  crura  furcata, 
causing  the  folds  of  the  ear  to  seem  obliterated.  Such  ears  are  smooth, 
larger  than  usual,  prominent,  and  have  a  thin  edge. 


Plate  3  a. 


MARX  SEVERE 

Mnnth 

SEIZURES  WITH  > 

Month 

.     PUT  D  AFTER 

Mnnth 

5AY  SEIZURES. 

Month 

1 

2 

3 

4 

5 

1 

2 

3 

4 

5 

1 

2 

3 

41 

5 

1 

2 

3 

4 

5 

QO 

Q 

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O 

D 

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Q 

(  ) 

() 

() 

:; 

6 

7 

8 

9 

10 

6 

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9 

10 

6 

7!8 

9 

10 

6 

7 

8 

9 

10 

Qonoonnnr 

Q 

on 

Q 

O 

O 

() 

O 

() 

ii 

12 

13 

14 

15 

11  |12|13|14|15 

11  12  13 

14 

15 

11 

12 

13 

14 

15 

QQooonnnoo 

ooo 

ODOOOO 

1617 

18 

19 

2016  1718  19  20 

16J17  18 

19 

20 

16 

17 

18 

19 

20 

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onn 

Q 

(   ) 

OQQQQ 

21 122,2324-25  21  22  2324-25 

2122  23 

2425 

21 

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QDQUC 

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28 

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30 

26 

27 

28 

29 

30 

a 

a 

O 

or) 

() 

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rpioon 

QQGOQ 

31 

U 

Total  Severe 

31    Total  Mild. 

Ol  Total  Severe 

31      Total  Mild- 

O  |  Total  Severe 

31 

Q 

Total  Mild 

Total  Severe 

MARK  MILD  SE 

Month 

IZURES  WITH  O. 

Month 

>UT    N  AFTER  NIC 

Mnnth 

HT  SEIZURES. 

Mnnth 

J-,* 

3   4-5 

1  12    3  |4  |6 

1 

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4 

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16 

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17 

18 

19 

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16 

17 

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19 

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161 

17 

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26 

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31 

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7W  Mild- 
Total  Severe 

31 

D 

Total  Mild 

Total  Severe 

31 

D 

Total  Severe 

Month 

ARK  "MZZY  SPEL 

Month 

LS"  WITH  DOT     • 

Mnnth 

Mnnth 

1 

2 

3 

4 

5 

t 

2  |3 

4 

5 

1 

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21 

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(   ) 

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1 

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26 

27 

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o 

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n 

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0 

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D 

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31 
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Total  Mild 

Total  Severe 

31 

a 

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Total  Severe 

31 

2 

Total  Mild 

Total  Severe 

31 

Total  Mild 

Total  Severe 

Facsimile  (reduced)  of  a  folder  card  designed  by  the  author,  to  be 
carried  by  the  patient  for  keeping  a  record  of  epileptic  seizures.  All 
attacks  for  twelve  months  can  be  entered  on  it,  the-  character  of  each 
attack  being  noted.  A  dietary  for  epileptics  is  printed  on  the  back  of  the 
original. 


THE    PHYSICAL    EXAMINATION.  45 

Anomalies  of  sensory  functions : 

Deaf -mutism,  neuralgia,  migraine,  and  vari- 
ous ocular  defects. 
Anomalies  of  speech : 

Mutism  and  stammering. 
Anomalies  of  the  genito-urinary  functions : 

Sexual  irritability,  impotence,  and  sterility. 
Anomalies  of  restraint  or  appetite : 

Uncontrollable   desire  for  food,   liquor,   and 
drugs;   lessened  resistance  against  disease; 
retardation  of  puberty. 
Psychic  Stigmata. 

All  degrees  of  mental  impairment : 

Insanity,  idiocy,  imbecility,  feeble-minded- 
ness,  precocity,  marked  eccentricity,  moral 
delinquency,  and  sexual  perversion. 

Deformities  of  the  cranium,  palate,  face,  and  ears 
are  among  those  most  commonly  observed,  the  accom- 
panying illustrations  (Figs,  i  to  8  inclusive)  showing 
the  more  common  types. 

THE  KEEPING  OF  SEIZURE  RECORDS. 

In  addition  to  the  seizure  data  kept  by  the  physician, 
it  is  well  to  place  in  the  possession  of  the  patient  a 
card  so  arranged  that  he  or  his  friends  may  readily 
enter  on  it  the  date  and  character  of  every  convulsion. 
The  card  should  also  contain  the  patient's  name  and 
address,  for  use  in  case  of  accident. 

The  possession  of  such  a  card  may  prevent  the 
patient  considerable  annoyance  should  he  commit 
unreasonable  acts  while  in  an  epileptic  or  automatic 
state  for  which  he  is  in  nowise  responsible. 


CHAPTER  III. 
FREQUENCY,  AGE,  SEX,  RACE,  AND  OCCUPATION. 

Proportion  of  Epileptics  to  the  General  Population.  The  Age  of  Greatest 
Development.  The  Influence  of  Heredity  on  Age.  Comparative  Fre- 
quency in  the  Two  Sexes.     Race.     Occupation. 

FREQUENCY. 

It  is  difficult  to  reach  an  accurate  conclusion  as  to 
the  frequency  of  a  disease  so  unobtrusive  in  its  mani- 
festations as  epilepsy  not  infrequently  is,  and  so 
universal  in  extent,  geograpically  speaking,  as  to 
apparently  exempt  none  of  the  races  of  the  earth. 

It  cannot  be  found  that  any  estimate  of  the  pro- 
portion of  epileptics  to  the  population  at  large  was 
made  until  after  the  epileptic  began  to  be  a  public 
charge  in  some  of  the  countries  of  continental  Europe, 
about  half  a  century  ago — in  France,  in  1849;  in  Ger- 
many, in  1867. 

Chiefly  through  reports  *  made  to  the  National 
Association  for  the  Study  of  Epilepsy  and  the  Care 
and  Treatment  of  Epileptics  in  this  country  in  1901 
and  1902,  a  fair  estimate  may  be  made  of  the  preva- 
lence of  epilepsy  in  this  and  foreign  countries. 

Kolle  gives  the  proportion  of  epileptics  in  Switzer- 
land as  1  to  750. 

Kovalevsky  states  that  the  proportion  in  Russia  is 
1  to  2000,  as  a  general  rule,  there  being  80,000  in  that 
country  all  told,  adding  that  the  proportion  in  the 
great  wine-drinking  provinces  of  Caucasus  is  much  in 

*  "Transactions  of  the  National  Association  for  the  Study  of  Epilepsy 
and  the  Care  and  Treatment  of  Epileptics,"  1901  and  1902. 

46 


AGE.  47 

excess  of  this ;  while  Shoutelwort  and  others  state  that 
one  person  out  of  every  iooo  in  Russia  suffers  from 
epilepsy. 

Pelmann  estimates  the  number  in  Scotland  at  15 
in  every  10,000,  or  1  to  every  750,  making  6000  in 
Scotland  alone. 

Vernet,  basing  his  figures  on  those  made  by  Lunier 
in  1 881,  places  the  proportion  in  France  at  9.2  for 
every  10,000  inhabitants,  making  the  enormous  num- 
ber of  33,225  in  the  French  Republic. 

Jules  Morel  estimates  the  number  of  epileptics  now 
under  family  care  in  Belgium  at  from  3500  to  4000, 
exclusive  of  the  large  number  in  the  Colony  at  Gheel. 

Basing  his  estimate  on  statistics  gathered  in  many 
States  in  this  country,  including  New  York,  New 
Jersey,  Connecticut,  Massachusetts,  Virginia,  Illinois, 
Indiana,  Texas,  and  others,  Peterson  estimates  the 
ratio  of  epileptics  to  the  population  at  large  in  the 
United  States  at  1  to  500,  making  the  tremendous 
aggregate  of  from  140,000  to  150,000. 

I  do  not  feel  that  this  estimate  is  too  high.  In- 
deed, it  is  scarcely  high  enough,  for  there  are  many 
cases  of  the  milder  forms  that  go  unrecognized,  and 
others  still  which,  through  feelings  of  pride,  or  other 
motives,  are  kept  concealed,  so  that  they  are  never 
included  in  any  census  that  is  made. 

The  author's  personal  knowledge  of  many  cases 
under  both  these  heads  leads  him  to  believe  that  the 
estimate  of  one  epileptic  to  every  500  inhabitants  of 
the  country  at  large  is  not  too  high.  As  compared 
with  insanity,  it  is  safe  to  say  that  epilepsy  is  a  little 
more  than  half  as  common  as  that  disease. 

AGE. 

Epilepsy  is  a  disease  of  all  ages.  On  this  point  all 
observers  agree.  In  latent  form  it  may  be  in  the 
infant   at  birth,   or  it   may   not   appear  until   senile 


48         FREQUENCY,    AGE,    SEX,    RACE,    OCCUPATION. 

changes  are  well  established,  at  seventy  years  or 
beyond.  Observers  also  agree  that  it  is  far  more 
common  during  the  first  twenty  years  or  so  of  life 
than  during  any  period  thereafter. 

Gowers  *  sums  up  his  age  studies  of  the  disease  as 
follows : 

"More  than  a  quarter  of  all  cases  begin  under  the 
age  of  ten  years ;  nearly  half  between  ten  and  twenty ; 
about  a  seventh  between  twenty  and  thirty;  a  sixth 
between  thirty  and  forty;  about  2\  per  cent,  only 
between  forty  and  fifty;  1  per  cent,  only  between  fifty 
and  sixty;  after  which  half  of  1  per  cent,  only  occur. 
Seventy-four  per  cent,  of  the  total  number  of  cases 
begin  under  twenty. ' ' 

A  closer  analysis  is  also  made  by  the  same  author 
in  which  he  gives  the  number  for  each  year  from  1 
to  7 1 ,  a  summary  of  which  is  as  follows : 

A  large  number  of  cases,  no  less,  than  13^  per  cent, 
of  the  whole,  began  during  the  first  three  years  of 
life. 

In  this  group  no  case  of  simple  infantile  convulsions 
is  included;  only  such  as  began  in  infancy  and  con- 
tinued as  chronic  epilepsy. 

Of  about  a  third  all  that  could  be  learned  was  that 
they  began  in  infancy.  In  making  up  the  table  these 
were  distributed  through  the  first  three  years  of  life 
in  the  same  proportion  as  presented  by  the  two-thirds 
in  which  the  exact  date  of  commencement  could  be 
ascertained.  The  number  of  cases  is  largest  at  the 
first  year;  falls  rapidly  to  the  third  year  of  age,  then 
more  slowly  until  five,  when  the  minimum  for  the 
early  period  of  life  occurs. 

From  this  there  is  a  considerable  rise  at  seven,  the 
commencement  of  the  second  dentition,  then  a  fall  at 
eight,  from  which  the  number  increases  slowly  at  nine 
and  ten,    rapidly   at   twelve   until   the   maximum   is 

*  "Epilepsy  and  Other  Chronic  Convulsive  Diseases,"  1901. 


AGE. 


49 


reached  at  fifteen  or  sixteen,  at  which  166  and  167 
cases  occurred.  From  this  time  there  is  rapid  fall  to 
twenty-one,  after  which  only  a  few  cases  began  each 
year. 

The  table  that  follows  is  made  up  from  a  series  of 
1302  cases  wrhich  came  under  the  writer's  observation 
during  a  period  of  eight  years,  and  shows  the  number 
of  cases  that  occurred  each  year  from  1  up  to  70 : 


Year. 

Cases. 

!  Year. 

Cases. 

Year. 

Cases. 

Year. 

Cases. 

I 

163 

19 

33 

37 

7 

55 

1 

2 

67 

20 

26 

3§ 

5 

56 

1 

3 

48 

21 

27 

39 

3 

57 

2 

4 

33 

22 

16 

40 

3 

58 

0 

5 

3° 

23 

15 

41 

2 

59 

0 

6 

43 

24 

6 

42 

5 

60 

1 

7 

48 

25 

7 

43 

3 

61 

0 

8 

54 

26 

12 

44 

3 

62 

1 

9 

48 

27 

10 

45 

4 

63 

0 

10 

56 

28 

10 

46 

3 

64 

0 

11 

48 

29 

6 

47 

3 

65 

2 

12 

7i 

3° 

5 

48 

0 

66 

6 

13 

56 

31 

6 

49 

1 

67 

1 

14 

84 

32 

6 

5° 

1 

68 

0 

15 

59 

33 

4 

5i 

2 

69 

0 

16 

43 

34 

5 

52 

1 

70 

1 

17 

44 

35 

9 

53 

0 

18 

32 

36 

4 

54 

2 

It  is  observed .  from  this  table  that  the  greatest 
number  occurred  during  the  first  year,  that  they  then 
regularly  declined  until  the  sixth  year,  when  the  num- 
ber rose  again  during  the  second  dentition,  to  drop  off 
very  slightly  during  the  ninth  year,  when  48  only 
occurred;  after  which  a  third  increase  began,  reaching 
a  maximum  at  fourteen,  when  84  cases  occurred,  fol- 
lowed by  the  final  decline  to  the  seventieth  year,  only 
67  cases  out  of  the  1302  having  occurred  after  the 
thirty-fifth  year. 

By  changing  the  yearly  table  into  decimal  periods 
we  find  the  number  and  percentage  for  each  age  period 
to  be  as  follows : 
4 


50         FREQUENCY,    AGE,    SEX,    RACE,    OCCUPATION. 


Under  10  years 

10  to  20  " 

19  to  29  " 

29  to  39  " 

39  to  49  " 

49  to  59  " 

59  to  69  " 


499 
566 

125 
54 
27 
11 


38.5  per  cent,  of  the  total  number. 
43-5 

9-5 

4 

2 

i-75 


It  may  now  be  recalled  that  the  classification  scheme 
presented  in  the  previous  chapter  was  largely  based  on 
three  age  periods,  the  first  including  the  first  three 
years;  the  second,  the  fourth  to  the  twentieth,  inclu- 
sive ;  the  third,  the  remainder  of  life.  We  can  better 
appreciate  the  practical  importance  of  this  after  ob- 
serving that  2 1  per  cent,  of  all  cases  began  during  the 
first  period,  and  62^  per  cent,  during  the  second, 
leaving  an  average  of  but  a  fraction  over  1  per  cent, 
for  each  year  thereafter. 

Our  studies  furthermore  show  that  more  than  83 
per  cent,  of  all  cases  begin  under  the  twentieth  year 
as  compared  with  76  per  cent,  given  by  Gowers. 

The  table  below  shows  very  comprehensively  the 
tendency  of  the  disease  to  decline  with  the  increasing 
age  of  the  patient,  the  studies  not  being  carried  beyond 
the  fortieth  year  because  of  the  rarity  of  the  develop- 
ment of  the  disease  de  novo  after  that  period. 


Under  5  years 

346—26^ 

per 

cent. 

5  to    9  years 
10  to  14      " 

inclusive. 

249— 19J 
318— 24! 

tt 

15  to  19      " 

■■in mi 

178-13! 

tt 

20  to  24      " 

^^H^H 

7i—  5* 

" 

25  to  29      " 

mmmm 

43—  3$ 

" 

3°  t0  34      " 

■a 

3°—  2£ 

" 

35  to  39      " 

~ 

22—  if 

AGE. 


THE  INFLUENCE  OF  HEREDITY  ON  AGE. 

Although  the  study  of  hereditary  influences  properly 
belongs  under  etiology,  it  is  of  interest  to  allude  to 
it  here,  so  far  as  it  has  bearing  on  the  age  periods 
that  aid  in  bringing  its  influences  to  light,  and  the 
detailed  statement  that  follows  shows  the  age,  up  to 
the  forty-fifth  year,  at  which  all  hereditary  influences 
are  most  active,  also  their  comparative  effect  on  the 
two  sexes  at  the  same  age : 


Year. 

Heredity  or  no 
Heredity. 

Males. 

Females. 

j  Year. 

Heredity  or  no 
Heredity. 

Males. 

Females. 

i 

Heredity. 

49 

39 

24 

Heredity. 

2 

2 

None. 

5i 

28 

None. 

0 

0 

2 

Heredity. 

28 

10 

25 

Heredity. 

3 

0 

None. 

21 

15 

None. 

3 

2 

3 

Heredity. 

17 

7 

26 

Heredity. 

2 

0 

None. 

14 

7 

None. 

5 

2 

4 

Heredity. 

19 

8 

27 

Heredity. 

2 

2 

5 

Heredity. 

6 

7 

None. 

3 

2 

None. 

12 

5 

28 

Heredity. 

2 

0 

6 

Heredity. 

5 

10 

None. 

4 

4 

None. 

21 

8 

29 

Heredity. 

4 

0 

7 

Heredity. 

14 

12 

None. 

0 

0 

None. 

15 

7 

30 

Heredity. 

3 

0 

8 

Heredity. 

22 

7 

None. 

0 

0 

9 

Heredity. 

15 

10 

31 

Heredity. 

0 

0 

None. 

19 

3 

None. 

3 

0 

10 

Heredity. 

16 

13 

32 

Heredity. 

2 

0 

None. 

22 

5 

None. 

3 

0 

ii 

Heredity. 

16 

5 

33 

Heredity. 

0 

0 

None. 

20 

12 

None. 

0 

0 

12 

Heredity. 

17 

19 

34 

Heredity. 

2 

0 

None. 

15 

19 

None. 

0 

0 

13 

Heredity. 

10 

15 

35 

Heredity. 

2 

0 

None. 

10 

15 

None. 

3 

4 

H 

Heredity. 

27 

18 

36 

Heredity. 

0 

0 

None. 

21 

12 

None. 

2 

0 

15 

Heredity. 

18 

3 

37 

Heredity. 

3 

0 

None. 

14 

12 

None. 

2 

2 

16 

Heredity. 

8 

II 

38 

Heredity. 

2 

0 

None. 

17 

5 

None. 

2 

0 

17 

Heredity. 

9 

8 

39 

Heredity. 

0 

0 

None. 

12 

13 

None. 

4 

0 

18 

Heredity. 

6 

7 

40 

Heredity. 

0 

0 

None. 

8 

8 

None. 

2 

0 

19 

Heredity. 

12 

2 

41 

Heredity. 

0 

0 

None. 

5 

9 

None. 

O 

0 

20 

Heredity. 

3 

4 

42 

Heredity. 

0 

0 

None. 

12 

7 

None. 

3 

0 

21 

Heredity. 

9 

5 

43 

Heredity. 

0 

0 

None. 

6 

4 

None. 

0 

0 

22 

Heredity. 

4 

3 

44 

Heredity. 

0 

0 

None. 

5 

3 

None. 

0 

0 

23 

Heredity. 

4 

3 

45 

Heredity. 

0 

0 

None. 

2 

2 

None. 

0 

0 

This  table  shows  conclusively  that  inherited  causes 
play  their  most  important  role  in  early  life.     Eighty- 


52         FREQUENCY,    AGE,    SEX,    RACE,    OCCUPATION. 

eight  out  of  163  cases  which  occurred  during  the  first 
year  were  ascribed  to  heredity.  During  the  second 
year  38  out  of  67  were  due  to  the  same.  During  the 
third  year  23  out  of  48,  the  same  proportion  (about 
50  per  cent.)  keeping  up  throughout,  for  as  the  number 
of  cases  increases  during  the  second  dentition  and 
puberty  periods,  the  hereditary  influence  is  increased 
in  corresponding  ratio. 

After  the  twentieth  year  the  influence  of  heredity 
rapidly  declines,  and  disappears  almost  completely  by 
the  fortieth  year,  there  being  but  a  few  isolated  cases 
after  that  in  which  such  a  factor  could  be  traced. 

In  all  studies  bearing  on  the  age  at  which  epilepsy 
develops,  and  the  influence  of  heredity  at  different 
ages,  the  further  investigation  is  carried  the  more 
firmly  is  the  student  convinced  that  epilepsy  is  essen- 
tially a  disease  of  early  life,  with  heredity  as  an  influ- 
ential or  contributing  cause  in  a  large  proportion  of 
all  cases. 

RATIO  OF  FREQUENCY  IN  THE  TWO  SEXES. 

There  exists  a  considerable  diversity  of  opinion 
among  some  of  the  most  noted  writers  on  epilepsy  as 
to  its  comparative  frequency  in  the  two  sexes. 

Gowers  is  authority  for  the  statement  that  women 
suffer  from  epilepsy  rather  more  than  men,  the  propor- 
tion being  thirteen  of  the  former  to  twelve  of  the 
latter. 

Fere  *  says :  "  Nearly  all  authors  admit  that  epilepsy 
is  more  frequent  in  women."  The  statistics,  however, 
upon  which  these  writers  base  their  opinions  are  not 
available  for  comparison. 

Hare  f  seems  to  place  little  reliance  on  some  of  the 
figures  made  by  well-known  authors  covering  this 
point,  and  mentions  Esquirol  and  Moreau  as  believing 

*  "Epilepsy,"  "Twentieth  Century  Practice  of  Medicine,"  Vol.  x,  p.  618. 
t  "Epilepsy;  Its  Pathology  and  Treatment,"  p.  102. 


RATIO    OF    FREQUENCY    IN    THE    TWO    SEXES.  53 

with  Gowers  that  epilepsy  is  more  common  among 
women  than  among  men,  adding:  "  Other  figures  made 
by  Englishmen  collected  by  the  writer  combat  the 
views  of  these  three  writers  by  placing  the  greater 
number  of  cases  among  men." 

"Boyd,"  says  the  same  author,  "in  studying  145 
cases  found  a  third  more  men  than  women.' 

Althaus  *  collected  in  all  over  54,000  cases,  dividing 
them  into  five-year  periods,  beginning  in  1847  and 
ending  in  1871,  28,690  of  them  being  men,  25,482 
women.     Hare  regarded  this  showing  as  conclusive. 

"  No  especial  influence,"  says  Osier, f  "appears  to  be 
discoverable  in  their  relation,  certainly  not  in  children. 
Of  433  cases  in  my  tables,  232  were  men  and  203  were 
women,  showing  a  slight  preponderance  of  the  male 
sex.  After  puberty,  unquestionably,  if  a  large  number 
of  cases  are  taken,  the  men  are  in  excess." 

Echeverria  studied  306  cases  of  epilepsy,  130  of 
them  being  men,  176  women;  adding  that  the  dispro- 
portion in  the  two  sexes  was  probably  due  to  some 
extent  to  the  amount  of  hospital  accommodations 
available  for  each. 

English  writers  generally  are  credited  by  this 
author  with  reporting  more  male  than  female  epi- 
leptics. 

The  United  States  Census  Bureau  reports  deaths 
from  epilepsy  in  the  United  States  for  the  "census 
years"  (every  tenth  year)  from  i860  to  1900,  as 
follows : 

Census  Total  Deaths 

Years.  from  Epilepsy.  Males.  Females. 

i860 501  284  217 

1870 1414  778  636 

1880 2157  1215  942 

1890 2367  1316  1004 

19°° 3326  IQI5  J4H 

*  "Diseases  of  the  Nervous  System,"  p.  222. 

f  "The  Principles  and  Practice  of  Medicine,"  1902,  p.  1094. 


54         FREQUENCY,    AGE,    SEX,    RACE,    OCCUPATION. 

According  to  these  figures  there  occurred  in  the 
five  census  years  only,  a  total  of  9718  deaths  from 
epilepsy  in  the  United  States;  5508  of  them  were 
men  and  4210  were  women,  an  excess  of  1298,  or  25 
per  cent,  of  the  former  over  the  latter.  In  1870, 
2.9  per  cent,  of  the  deaths  were  due  to  epilepsy;  in 
1880,  2.9  per  cent.;  in  1890,  2.8  per  cent.;  in  1900, 
3.2  per  cent. 

The  apparent  increase  in  the  number  of  deaths  may 
be  accounted  for  on  the  basis  of  more  carefully  com- 
piled statistics. 

Wharton  Sinkler  is  of  the  opinion  that  epilepsy  is 
more  common  among  men  than  among  women.  Out 
of  1204  cases  at  the  Orthopedic  Hospital  and  Infirmary 
for  Nervous  Diseases,  Philadelphia,  548  were  men,  476 
women. 

Mailhouse  (1902)  reported  542  in  Connecticut;  315 
men  and  227  women. 

In  a  total  of  324  cases  in  one  hospital  in  Virginia 
reported  by  Dr.  Drewry,  221  were  men,  103  women. 
This  observer  adds:  "In  the  statistics  I  collected  a 
few  years  ago  regarding  epileptics  in  Virginia,  I  found 
that  men  were  decidedly  in  excess  of  women." 

The  report  of  the  New  York  State  Lunacy  Commis- 
sion for  1900  shows  that  between  1888  and  1900,  616 
deaths  occurred  from  epilepsy  in  the  State  Hospitals  for 
the  Insane;  392  men  and  224  women. 

During  a  period  of  eight  years,  from  February  1 ,  1896, 
to  February  1,  1902,  histories  of  a  total  of  1582  well- 
authenticated  cases  of  epilepsy  came  to  the  author's 
notice,  951  of  which  were  men,  and  631  women. 

All  of  these  were  seeking  relief  in  a  special  institu- 
tion, and  the  fact  that  the  capacity  of  the  institution 
was  greater  for  men  than  for  women  may  have  caused 
a  smaller  number  of  women  applicants  to  appear ;  yet 
it  is  not  likely  that  a  sufficient  number  were  kept  from 
applying  to  account  for  the  great  discrepancy  between 


RACE.  55 

the  two  sexes  in  the  actual  number  who  did  apply.  In 
a  total  number  of  68,040  cases  mentioned  above, 
36,865  were  men,  31,175  women. 

It  is  the  author's  belief  that  epilepsy  is  more  fre- 
quent among  men  than  among  women,  in  the  propor- 
tion of  20  men  to  16  women  in  every  100  cases.  The 
apparent  failure  of  the  English  writers  to  indicate  the 
epilepsies  due  to  alcohol  and  syphilis  which  occur  most 
often  in  men  in  middle  life  may  partly  account  for 
their  views  on  the  preponderance  of  the  disease  in  the 
female  sex. 

Through  the  period  during  which  heredity  plays  its 
most  active  part  there  is  less  difference  in  the  number 
between  the  two  sexes  than  later  on,  but  after  that 
the  fact  that  men  suffer  more  accidents  which  cause 
traumatic  epilepsy,  more  often  have  syphilitic  infec- 
tion of  the  brain,  and  are  more  commonly  given  to 
indulgence  in  alcoholic  drink,  are  the  chief  reasons  why 
epilepsy  is  more  frequent  in  the  male  sex. 

RACE. 

In  the  same  way  in  which  epilepsy  makes  no  dis- 
tinction in  the  social  status  or  condition  of  those  it 
affects,  it  makes  equally  as  little  so  far  as  race  is 
concerned. 

Naturally  the  greater  number  of  cases  occurring  in 
any  one  country  under  usual  conditions,  would  be 
among  the  people  of  that  country,  and  merely  to  give 
some  idea  of  the  universal  character  of  the  disease, 
I  mention  the  following  countries,  exclusive  of  the 
United  States,  as  contributing  to  cases  I  have  studied 
since  1895:  Germany,  England,  Russia,  Ireland, 
Canada,  Austria-Hungary,  Sweden,  Italy,  Switzerland, 
Japan,  France,  Roumania,  Arabia,  and  Belgium.* 

*  Among  the  races  of  other  countries  known  through  reports  to  the 
National  Association  for  the  Study  of  Epilepsy  and  the  Care  and  Treatment 
of  Epileptics,  to  suffer  from  Epilepsy,  are :  Turkey,  India,  Australia,  Chili, 
and  Brazil.     "Epilepsy  is  very  common  in  all  parts  of  Brazil"  (Hoaelburg) 


56         FREQUENCY,    AGE,    SEX,    RACE,    OCCUPATION. 

Out  of  a  total  of  1 3  2  2  in  which  the  race  was  definitely 
ascertained,  57  in  all,  41  men  and  16  women,  were  of 
the  Jewish  race,  while  two  were  American  Indians, 
one  of  each  sex,  and  both  under  fifteen  years  of  age. 

Searcy,  who  has  had  exceptional  opportunities  for 
studying  epilepsy  and  insanity  in  the  negro  race  in 
the  Southern  States,  says:* 

"There  are  about  thirteen  times  as  many  insane 
negroes  under  state  care  now  in  Alabama  as  there 
were  thirty  years  ago.  In  1870  there  were  33  insane 
negroes  in  our  hospital;  in  1880,  71;  in  1891,  241; 
in  1900,  451." 

"  It  is,"  he  adds,  "  a  generally  expressed  opinion  that 
insanity  and  epilepsy  are  rapidly  increasing  among 
the  negroes.  Many  lines  among  them  are  degenerating 
and  epilepsy  and  insanity  are  but  indications  and 
results  of  it.  The  Africans  in  America  came  out  of 
their  servitude  an  inherently  improved  people,  men- 
tally and  physically.  While  they  were  slaves  there 
was  little  deterioration  among  them,  consequently, 
little  insanity. ' ' 

Viewed  solely  from  its  scientific  and  hygienic  side, 
the  lessons  taught  by  the  history  of  the  negro  race  in 
the  South  under  slavery,  when  their  habits,  appetites, 
and  tendencies  to  dissipation  were  largely  regulated 
and  controlled,  and  under  freedom  from  slavery,  when 
all  these  hurtful  tendencies  were  allowed  to  run  full 
riot,  are  of  undoubted  value  to  the  student  who  is 
looking  for  the  great  causes  that  degrade  and  destroy 
the  mental  and  physical  life  of  the  people  who  practise 
them. 

OCCUPATION. 

So  far  as  I  have  been  able  to  ascertain,  occupatipn 
has  no  influence  in  the  production  of  epilepsy. 

While  it  is  true  that  we  find  the  great  majority  of 
cases  among  representatives  of  certain  callings,  it  is 

*  "Report  of  the  Alabama  Bryce  Insane  Hospital,"  1902. 


OCCUPATION.  57 

due  to  the  relatively  greater  number  engaged  in  such 
callings  and  not  to  any  specific  influence  exerted  by 
the  form  of  occupation  itself. 

We  found  702  epileptics  out  of  1322  following  one 
or  the  other  of  these  vocations:  Mechanic,  farmer, 
laundryman,  seamstress,  painter,  porter,  merchant, 
musician,  messenger,  peddler,  barber,  clerk,  printer, 
nurse,  engineer,  railway  conductor,  sailor,  bartender, 
plumber,  bookkeeper,  tailor,  lawyer,  teacher,  dentist, 
clergyman,  student,  photographer,  mason,  shoemaker, 
drummer,  letter-carrier,  cooper,  fireman,  flagman, 
draughtsman,  upholsterer,  newsboy,  teamster,  coach- 
man, watchmaker,  and  others. 

Six  hundred  and  twenty,  nearly  50  per  cent.,  had 
no  occupation  of  any  kind.  The  occupations  of 
housewife  or  domestic  furnished  the  greatest  number 
of  any  single  calling;  195,  equal  to  about  15  per  cent., 
coming  under  these  heads. 

Laborers  stand  second  in  frequency ;  farmers,  third ; 
mechanics,  fourth;  while  clerks  and  students  stand 
fifth,  with  the  same  number,  50,  each. 

Under  this  heading,  were  it  within  the  province  of 
this  work,  we  might  study  to  advantage  the  ethic 
and  economic  side  of  the  effects  of  epilepsy — a  disease 
which  often  impairs  or  completely  destroys  the  use- 
fulness of  its  victim  in  the  commercial  and  social 
world,  without  any  appreciable  impairment  of  mind 
or  body,  the  knowledge  of  the  presence  of  epilepsy, 
no  matter  how  mild  or  infrequent  the  attacks  may  be, 
sufficing  to  make  the  epileptic's  presence  undesirable. 

But  such  considerations  hardly  fall  within  the  scope 
of  our  present  studies. 


CHAPTER  IV. 
ETIOLOGY.— PART  I. 

Heredity:  Similar  and  Dissimilar.  Consanguinity.  The  Causes  Active  in 
Early  Life.  The  Infectious  Fevers:  Scarlet  Fever;  Typhoid  Fever;  Measles; 
Diphtheria;  Malaria.     Emotional  Shock  and  Fright. 

We  may  assemble  the  causes  of  all  epilepsies  pri- 
marily under  two  heads : 

Predisposing. 

Exciting. 

Under  the  former  will  be  studied  the  comparatively 
few  factors  that  prepare  the  individual  to  acquire  the 
disease,  but  which  may  not  actually  produce  it ;  under 
the  latter,  as  many  as  possible  of  the  numerous  factors 
that  actually  produce  epilepsy  with  or  without  the  aid 
of  influences  that  predispose  to  it. 

In  the  majority  of  cases  both  predisposing  and  excit- 
ing causes  play  a  part  and  are  complemental  to  each 
other.  This  well-known  fact  we  may  illustrate  in 
this  way:  Given  an  individual  in  whom  epilepsy  may 
be  induced  under  the  influence  of  some  irritation  of 
which  the  climax — i.  e.,  the  point  at  which  it  causes 
the  seizure  to  appear — is  represented  by  ioo.  If  there 
are  already  present  60  of  these  points  from,  we  will 
say,  a  predisposition  due  to  heredity,  there  will  remain 
but  40  points  to  be  supplied  by  some  exciting  cause 
to  bring  the  disease  to  light ;  this  exciting  cause  being, 
perhaps,  one  of  the  specific  fevers,  some  kind  of 
toxemia,  an  emotional  shock,  an  acute  attack  of  in- 
digestion, trauma,  some  reflex  irritation,  or  numerous 
other  causes  that  will  be  fully  described  later  on. 

On  the  other  hand,  if  we  say  there  are  but  40  points 

5S 


CAUSES    OF    EPILEPSY.  59 

of  a  predisposing  cause  present,  and  the  "  seizure  point" 
is  the  same  as  before  (ioo),  it  will  require  60  points  of 
the  exciting  cause  instead  of  40  to  develop  the  convul- 
sion. 

In  other  words,  epilepsy,  etiologically  considered,  is 
often  a  symptom-complex  dependent  in  the  great 
majority  of  cases  upon  two  variables;  either  a  maxi- 
mum of  inherited  influence  combined  with  a  minimum  of 
exciting  cause,  or  a  minimum  of  inherited  influence 
combined  with  a  maximum  of  exciting  cause. 

The  fact  that  heredity,  both  similar  and  dissimilar, 
plays  such  an  important  part  in  the  production  of 
epilepsy  is  so  universally  recognized  that  I  will  omit 
all  but  a  few  authoritative  opinions  on  this  point : 

"  Epilepsy  is  an  inherited  disease."  * 

"There  are  few  diseases  in  the  production  of  which 
inheritance  has  more  manifest  influence,  and  the  trace- 
able influence  is  always  far  less  than  that  which 
exists,  "f 

"The  significance  of  this  (heredity)  at  the  present 
day  no  longer  needs  to  be  proved  by  statistics  and 
special  instances ;  it  is  a  fact  noticed  and  conceded  by 
all  observers. "J 

"Hereditary  transmission  of  epilepsy  may  be  direct 
or  indirect ;  that  is  to  say,  it  may  be  affected  through 

the  antecedents  or  through  the  collaterals 

Dissimilar  heredity  has  long  been  recognized  in 
epileptics."  § 

' '  Heredity  is  the  great  factor  in  mental  and  nervous 
diseases.     In  epilepsy  it  also  plays  the  chief  role."  || 

"  Heredity  is  the  most  potent  of  any  single  in- 
fluence."** 

*  Gowers,  Allbutt's  "System  of  Medicine,"  p.  763. 

t  Gowers,  "Epilepsy  and  Other  Convulsive  Diseases,"  p.  3. 

%  Nothnagel,  "Cyclopedia  of  the  Practice  of  Medicine,"  Ziemssen,  p.  201. 

§  Fere,  "Twentieth  Century  Practice,"  Vol.  x,  p.  616. 

||  Voisin,  "L'epilepsie,"  1897,  p.  6. 

**  Dana,  "Nervous  Diseases,"  ed.  1897,  p.  464. 


60  ETIOLOGY. 

"The  children  of  epileptics  are  frequently  insane, 
idiotic,  or  hysterical,  and  the  descendants  of  an  insane 
person  are  often  epileptic,  idiotic,  or  insane,  or  their 
epilepsy  passes  into  insanity,  or  epilepsy  supervenes 
upon  idiocy."* 

Whatever  skepticism  one  might  feel  about  the  in- 
influence  of  heredity  when  entering  upon  the  system- 
atic, intimate  study  of  hundreds  of  cases,  much,  if  not 
all,  of  it  will  be  dispelled  before  the  end  of  many  years. 

All  close  students  of  nervous  diseases  come  sooner 
or  later  to  feel  the  force  of  Maudsley's  statement  con- 
cerning insanity  and  crime  when  he  says : 

"They  are  as  much  manufactured  articles  as  are 
steam  engines  and  calico  printing  machines.  They 
are  neither  accidents  nor  anomalies  in  the  universe, 
but  come  by  law  and  testify  to  causality,  and  it  is 
the  business  of  science  to  find  out  what  the  causes  are, 
and  by  what  law  they  work."f 

As  potent  as  are  the  influences  of  heredity  in  insan- 
ity and  crime,  they  are  none  the  less  so  in  epilepsy. 

But  heredity  is  not  the  only  cause;  indeed,  as  we 
shall  presently  see,  it  is  far  from  it.  My  chief  purpose 
in  bringing  it  so  clearly  into  the  foreground  is  because 
it  is  the  factor  we  should  command  ourselves  to  search 
for  first  in  each  case  that  comes  under  our  care.  If 
it  is  not  present,  all  the  better,  for  the  prospects  of 
amelioration  or  cure  will  be  proportionately  brighter; 
if  it  is  present,  we  should  know  it,  for  the  knowledge 
will  materially  help  to  guide  us  in  treatment,  espe- 
cially if  the  treatment  is  surgical  and  designed  to  re- 
move bodily  the  proximate  cause  of  the  disease  from 
the  brain. 

Some  of  the  most  notable  failures  in  the  surgical 
treatment  of  epilepsy  that  I  have  known  were  due  to 
failure  to  consider  heredity  when  it  constituted  the 

*  Ireland,  "Mental  Affections  of  Children,"  1900,  p.  14. 
t  Gorton,  "Ethics  of  Pauperism  and  Crime,"  1902,  p.  204. 


HEREDITY.  6 1 

sole  ascertainable  cause.  At  the  same  time,  we  should 
not  feel  that  hereditary  influences  are  fatal  to  ameliora- 
tion or  cure.  This  would  be  a  pessimistic  view  alto- 
gether unwarranted  by  the  plainest  teachings  of  ex- 
perience. 

It  has  come  to  be  regarded  that  no  matter  what  the 
cause,  if  the  mental  condition  of  the  patient  remains 
inherently  unimpaired,  improvement  is  always  pos- 
sible, and  even  cures  can  sometimes  be  wrought  when 
they  are  least  expected. 

It  will  be  profitable  now  to  go  back  and  take  up  the 
study  of  causes  somewhat  in  the  order  named  in  the 
classification  on  pages  30  to  32. 

HEREDITY. 

PREDISPOSING  CAUSES  ACTIVE  IN  EARLY  LIFE. 

Similar.  Dissimilar. 

In  which  the  disease  appears  in  the        In  which  the  disease  appears  in  the 

child  because  a  predisposition  to  it  child  because  a  predisposition  to 

was  acquired  from  the  parent  who  it  was  acquired  from  the  parent 

had  the  same  disease.  who    had    some    disease    of    the 

nervous  system  other  than  epi- 
lepsy, such  as  alcoholism  or  in- 
sanity. 

Both  similar  and  dissimilar  heredity  from  any  point 
of  view  constitute  predisposing  causes  only;  neither, 
in  all  probability,  can  actually  create  the  disease, 
although  the  immediate  exciting  agent,  in  some  in- 
stances, may  be  exceedingly  difficult  or  impossible  to 
determine,  at  least  in  the  present  state  of  our  know- 
ledge. 

And  why?  The  answer  to  this  at  once  carries  us 
over  into  a  consideration  of  the  probable  pathologic 
changes  involved  in  epilepsy,  and  since  we  shall  have 
frequent  occasion  for  referring  to  this  portion  of  the 
subject  before  we  come  to  the  chapter  on  Pathology, 
where  it   is   exhaustively  dealt  with,  we  will  briefly 


02  ETIOLOGY. 

discuss  the  changes  now  thought  to  underlie  the  epi- 
leptic state. 

It  is  generally  agreed  that  it  is  the  function  of  the 
nerve  cells  in  the  gray  matter,  the  cortex  of  the  brain, 
to  store  up  nervous  energy,  and  it  is  the  function  of 
this  energy  to  be  ready  for  release  the  moment  any 
call  is  made  upon  it.  Irrespective  of  the  source  from 
which  this  energy  is  derived  or  the  manner  in  which 
it  is  acquired,  it  must  be  taken  up  and  stored  by  the 
nerve  cells,  which  then  stand  charged  with  it,  so  to 
speak,  like  a  bucket  full  of  water,  in  a  state  of  the 
most  delicate  equilibrium. 

The  process  of  securing,  storing,  and  releasing 
nervous  energy  in  a  normal  way  may  seem  simple 
enough  at  first  glance,  if  viewed  merely  as  an  abstract 
physical  problem;  but  such  is  not  the  case,  for  it 
constitutes  the  sum  total  of  life  itself,  and  we  have 
absolutely  no  knowledge  of  the  intricate  principles 
of  the  vital  processes  involved;  the  only  two  things 
that  seem  reasonably  clear  being: 

First,  that  nervous  energy  is  secured  from  nutritional 
processes,  is  appropriated,  and  in  some  way  stored  up 
bv  the  nerve  cells. 

Second,  the  gradual  discharge  or  giving  off  of  this 
energy  to  meet  the  immediate  and  varying  demands 
of  the  entire  organism  for  all  the  purposes  of  life. 

The  nerve  cells'  income  of  force  or  energy  is  thus 
ordinarily  kept  equal  to  the  outgo  of  the  same  force. 
In  normal  nervous  action  any  discrepancy  in  these 
two  quantities  is  not  sudden,  sharp,  and  destructive, 
at  least  not  to  the  extent  it  is  in  epilepsy,  but  is 
gradually  discharged  through  legitimate  physiologic 
channels  under  inhibitory  processes  designed  to  regu- 
late the  supply  in  a  natural  way. 

If  the  power  of  the  nerve  cell  to  inhibit  itself  or  be 
inhibited  is  impaired  in  any  way,  either  through  a 
deficiency  or  weakness  that  existed  at  birth,  or  through 


HEREDITY.  63 

some  disease  that  appeared  after  birth,  it  will  release 
its  energy  in  an  irregular,  spasmodic  way,  which 
neurologists  agree  as  constituting  the  basic  cytologic 
changes  that  give  origin  to  the  epileptic  convulsion. 

Now  comes  the  question,  Why  do  nerve  cells  do  this  ? 
In  what  way  is  their  natural  ability  to  store  up  and  re- 
tain nervous  power  impaired? 

On  this  deeply  interesting  point  science  cannot  yet 
speak  with  any  degree  of  conviction.  It  assumes 
that  the  fault  lies  either  in  the  structural  malformation 
of  the  cell,  it  being  too  small  to  do  the  work  required 
of  it,  in  its  imperfect  insulation,  or  in  the  over-pro- 
duction of  nerve  force.  All,  or  any,  of  these  conditions 
are  assumed  to  be  present. 

It  seems  difficult  to  understand  how  a  nervous 
system,  frail,  unstable,  degenerate,  and  always  weak 
in  its  structural  composition  and  force,  can  rapidly 
store  up,  discharge,  and  re-accumulate  nervous  force 
of  the  degree  and  kind  required  to  create  epileptic 
manifestations  unless  its  power  of  inhibition  is  im- 
paired or  destroyed. 

Some  neurologists  appear  to  think  that  the  cause  of 
the  essential  epileptic  expression — the  convulsion 
itself — is  to  be  explained  wholly  on  the  ground  of  inef- 
fective inhibition. 

Nevertheless,  it  seems  reasonably  fair  to  assume 
that  the  delicacy  of  adjustment  between  the  chemical 
relations — the  tendency  of  the  atoms  to  unite  in  fresh 
and  closer  combinations  and  release  their  latent 
energy — is  very  great,  so  that  the  slightest  deviation 
from  the  normal  relation  between  the  molecules  over- 
turns equilibrium,  when  a  quick  combustion  and  sud- 
den release  of  energy  occur. 

The  causes  of  epilepsy  in  early  life  may  then  be  said, 
because  of  all  this,  to  be  more  largely  predisposing  than 
exciting,  the  predisposition  lying  in  an  inherently 
faulty  central  nervous  system  that  was  as  much  a  part 


64  ETIOLOGY. 

and  parcel  of  the  child  at  the  moment  of  its  birth  as 
was  the  shape  of  its  ear  or  the  color  of  its  eyes. 

Now,  add  to  this  inherited  fault  some  exciting  cause, 
some  form  of  "  stress,"  and  the  cause  is  complete — the 
individual  is  ready  for  epileptic  manifestations. 

PROPORTION  OF  CASES  DUE  TO  SIMILAR  HEREDITY. 

In  one  series  of  1070  cases  that  came  under  the 
writer's  observation — 660  men  and  410  women — 105 
of  the  men  and  73  of  the  women  had  the  disease  be- 
cause of  the  same  disease  in  the  parent. 

The  number  in  the  men  constituted  15  per  cent,  of 
the  total,  while  the  number  in  the  women  amounted 
to  1 7  per  cent,  of  the  total.  Combining  both  men  and 
women,  the  percentage  of  the  total  number  in  all  cases 
was  16.  It  appears  from  this  that  more  women  than 
men  have  epilepsy  as  a  direct  inheritance  from  the 
parent. 

It  would  be  interesting  to  compare  these  figures  with 
the  results  of  other  observers,  but  it  cannot  be  found 
that  any  one  else  has  tabulated  results  which  single 
out  similar  heredity  from  dissimilar  heredity,  such  as 
alcoholism  and  insanity  tend  to  confer. 

If  Gowers  included  in  his  studies  on  heredity  only 
those  cases  in  which  "like  comes  from  like"  his  results 
are  numerically  greater  than  those  obtained  by  the 
writer,  for  he  says: 

"Particulars  as  to  heredity  and  age  at  commence- 
ment were  noted  in  2222  cases,  in  888  of  which  heredity 
existed,  or  about  40  per  cent." 

In  the  absence  of  any  designation  to  the  contrary, 
I  incline  to  think  that  all  hereditary  factors,  similar 
and  dissimilar,  were  included  by  Gowers;  but  if  this 
is  true,  our. results  compared  with  his  will  again  differ, 
for,  combining  all  inherited  influences,  including 
epilepsy,  insanity,  alcoholism,  tuberculosis,  and  other 
diseases,  I  found  a  total  of  56  per  cent.,  or  16  per 
cent,  more  than  that  stated  by  Gowers. 


HEREDITY.  65 

It  has  been  claimed  that  inherited  epilepsy  always 
developed  before  the  age  of  twenty  years,  but  by  refer- 
ring to  the  table  on  page  51,  in  which  is  shown  the 
number  of  cases  that  developed  in  the  two  sexes, 
from  the  first  year  up  to  the  forty-fifth,  it  will  be  seen 
that  this  is  a  mistake.  It  is  true  that  the  decline  in 
heredity  at  about  the  twentieth  year  is  very  marked, 
yet  we  note  that  28  cases  among  men  and  12  among 
women,  40  in  all,  began  between  the  twentieth  and 
thirtieth  year;  while  9  occurred  among  men  between 
the  thirtieth  and  fortieth  year ;  cases  occurring  in  either 
sex  after  that  age  were  not  ascribed  to  hereditary 
influences. 

It  is  worthy  of  note  that  no  women,  after  the 
thirtieth  year,  had  the  disease  as  a  result  of  heredity 
of  any  kind,  while  in  nine  men  it  was  the  ascribed 
cause.  This  seems  perfectly  reasonable  when  we  recall 
that  the  exciting  causes  in  men  about  this  age,  such 
as  alcohol,  syphilitic  infection,  and  various  forms  of 
trauma,  are  vastly  more  common  than  among  women. 

AN  ILLUSTRATION  OF  SIMILAR  HEREDITY. 

The  following  is  as  clear  a  case  of  similar  inherited 
epilepsy  as  I  have  ever  known,  and  is  reported  as  a 
typical  illustration  of  the  cause  under  discussion: 

C.  E.  M.  came  under  my  observation  in  1898,  being 
then  nineteen  years  of  age.  She  had  been  an  epileptic 
six  years,  the  cause  being  ascribed  to  "menstrual  dis- 
turbance. ' ' 

Her  family  history  was  not  good.  Her  father  had 
rheumatism;  her  mother  and  half-sister  died  of 
cancer.  The  patient  ' '  cried  almost  constantly, ' '  and 
"had  had  night  terrors  as  a  child."  She  had  a  con- 
vulsion during  the  first  dentition  and  a  second  one  at 
the  age  of  two  years,  having  been  free  from  them  after 
that  up  to  the  age  of  thirteen,  when  they  began  to 
appear  at  each  menstrual  epoch.  At  eighteen  years 
she   had   status   epilepticus,    which   came   very   near 


66  ETIOLOGY. 

destroying  her  life.  The  individual  attacks  were  of 
the  severest  kind. 

Eight  months  after  she  came  under  care,  she  gave  up 
treatment  and  returned  to  her  home,  having  improved 
greatly  in  that  time. 

In  the  fall  of  1902  she  re-appeared  under  another 
name,  having  been  married  about  two  years,  and  I 
learned  that  a  year  after  her  marriage  she  had  a  baby — ■ 
a  boy — who  seemed  well  and  strong  up  to  the  third 
month,  when,  without  any  appreciable  cause,  he  had  a 
severe  convulsion,  followed  two  months  later  by  a 
second,  and  a  month  later  by  a  third.  The  physician 
now  having  the  baby  under  his  care  reports  it  as  suf- 
fering from  established  epilepsy.* 

The  mother  of  this  child  unquestionably  inherited 
a  depraved  constitution,  and  had  she  not  been  obliged 
to  pass  through  the  disturbing  physiologic  epochs  that 
bring  to  light  the  weak  points  in  such  constitutions, 
she  might  have  gone  through  life  free  from  epilepsy. 

But  this  was  not  to  be,  for  the  first  dentition,  acting 
as  an  exciting  cause  on  a  constitution  made  ready  for 
disease  by  a  faulty  heritage,  provoked  the  first  con- 
vulsion, which  was  followed  by  others  made  easier  of 
development  through  the  beginning  of  the  "habitua- 
tion of  the  epileptic  habit,"  established  by  the  first 
fit. 

The  mother  is  now  twenty-three  years  old  and  has 
been  an  epileptic  ten  years;  yet,  because  the  brain 
has  a  predisposition  to  epilepsy  only — does  not  possess 
the  genuine  epileptic  dyscrasia,  the  convulsions  appear- 
ing as  the  result  of  an  irritation  outside  the  brain — 
she  still  has  a  good  mind,  and  should  she  follow  the 
usual  course  of  such  cases  she  may  continue  to  have 
the  full  use  of  all  her  mental  faculties,  even  though  she 
should  live  to  reach  the  age  of  sixty  or  seventy  years. 

Now,  contrast  this  very  probable  picture  with  the 

*  Shortly  after  this  was  written,  the  baby  died  of  cerebrospinal  men- 
ingitis. 


HEREDITY.  6f 

prospective  future  of  the  child  if  it  had  lived.  Born 
of  a  mother  burdened  with  a  strong  predisposition  to 
epilepsy,  it  did  not  wait  for  the  active  crisis  of  the  first 
dentition  epoch  to  excite  the  convulsive  habit,  but 
began  to  have  distinct  epileptic  seizures  at  three 
months;  and  had  death  not  occurred,  it  would  un- 
doubtedly have  become  an  epileptic  idiot  at  an  early 
age. 

The  cause  of  epilepsy  in  the  mother  was  dissimilar 
heredity,  plus  the  stress  of  the  first  dentition;  while 
the  cause  in  the  child  was  similar  heredity  plus,  may 
be,  some  slight  stress,  in  all  probability  nutritional  in 
kind,  but  the  exact  character  of  which  we  are  unable 
to  identify. 

PROPORTION  OF  CASES  DUE  TO  DISSIMILAR  HEREDITY. 

Alcohol. — The  same  group  of  1070  cases  that  yielded 
16  per  cent,  in  which  the  cause  was  similar  heredity, 
contained  in  men  and  51  women,  16  per  cent,  of  the 
former  and  1 2  per  cent,  of  the  latter,  in  which  the  dis- 
similar hereditary  factor  of  alcoholism  in  the  parent 
led  to  epilepsy  in  the  child. 

The  explanation  of  the  greater  preponderance  of 
epilepsy  due  to  drink  in  men  is  undoubtedly  due  to  the 
fact  that  the  drink  habit  is  more  marked  in  this  sex, 
a  fact  our  experience  tends  to  confirm  through  having 
seen  so  many  cases  among  middle-aged  men  due  to 
this  cause,  while  we  recall  but  a  single  case  in  which 
it  was  clear  that  drink  directly  brought  on  the  disease, 
or  laid  the  foundation  for  it,  in  a  woman. 

In  estimating  the  number  of  epileptics  in  different 
portions  of  Russia,  Kovalevsky  writes  as  follows:* 

"Caucasus  is  a  country  of  grape  and  wine-making. 
The  drinking-water  from  the  mountain  rivers  is  bad, 
but  the  wine  is  good.     The  natives  of  Caucasus  quench 

*  "Transactions  of  the  First  Annual  Meeting  of  the  National  Associa- 
tion for  the  Study  of  Epilepsy,"  1901,  p    168. 


68  ETIOLOGY. 

their  thirst,  not  with  water  but  with  wine,  and  the 
wine  is  no  light  one.  It  contains  from  5  to  15  per  cent, 
of  alcohol.  Wine-drinking  is  so  common  in  Caucasus 
that  no  one  considers  it  inebriety.  Everybody  knows 
what  a  high  percentage  of  epilepsy  is  caused  by  the 
abuse  of  alcoholic  beverages.  I  have  spent  the  sum- 
mers during  the  last  fifteen  years  in  Caucasus,  where 
I  have  a  medical  practice  drawn  from  a  large  district, 
and  in  no  other  place  have  I  had  so  large  a  proportion 
of  epileptics  among  my  patients." 

Of  such  vital  importance  and  so  full  of  interest  is 
the  whole  question  of  the  effects,  both  immediate  and 
remote,  of  alcohol  on  the  human  race,  that  I  quote 
literally  from  a  recent  Scottish  authority,  whose  valu- 
able work  deals  with  pathologic  factors  active  in 
uterine  life.  Under  a  study  of  fetal  alcoholism, 
Ballantyne  has  this  to  say: 

"Another  question  concerned  with  the  effects  of 
alcohol  upon  antenatal  life  remains  to  be  considered, 
namely,  the  dystrophic  and  teratological  results.  With 
regard  to  epilepsy  developing  after  birth,  there  is  a 
great  deal  of  evidence  that  parental  alcoholism  is  an 
immediate  and  powerful  etiologic  factor,  Fere,  Combe- 
male,  Leter,  Lancereaux,  Montpellier,  and  others 
having  written  on  this  subject;  while  Bourneville, 
who  studied  2554  children  admitted  to  the  Bicetre 
and  Fondation  Vallee — 2072  boys  and  482  girls — all 
of  them  suffering  from  idiocy,  epilepsy,  imbecility,  or 
hysteria,  found  that  1053  of  them  were  the  offspring 
of  drunken  parents,  933  having  drunken  fathers,  and 
80,   drunken  mothers. 

' '  Sullivan  found  that  out  of  2 1 9  children  of  alcoholic 
mothers  who  lived -beyond  infancy,  4  per  cent,  of  them 
became  epileptics;  a  very  high  proportion  as  com- 
pared to  the  frequency  of  the  disease  in  the  general 
population." 

Insanity. — It  appears  singular  that  insanity  should 


HEREDITY.  69 

constitute  a  less  predisposing  cause  to  epilepsy  than 
alcoholism,  but  such  is  the  case. 

In  660  men  and  410  women,  insanity  in  the  parents 
was  found  in  49  men  and  42  women,  or  7  per  cent, 
of  the  former  and  10  per  cent,  of  the  latter.  In  this 
case  the  conditions,  so  far  as  proportions  go  when 
compared  with  alcoholism,  are  reversed;  there  the 
greater  number  occurred  among  men,  while  here  it  is 
the  women  that  suffer  most. 

Combining  both  sexes,  we  have  a  total  of  91  cases, 
or  about  7  per  cent,  of  the  entire  1070,  due  to  dis- 
similar heredity  induced  by  insanity. 

Tuberculosis. — In  taking  up  tuberculosis  as  a  possible 
predisposing  factor  in  epilepsy,  we  are  treading  on 
delicate  ground.  So  far  as  I  have  been  able  to  as- 
certain, there  has  never  been  any  attempt  to  specific- 
ally connect  the  tuberculous  diathesis  in  the  parent 
with  epilepsy  in  the  child. 

We  have  simply  assumed  that  its  presence  in  the 
parent  gives  the  child  a  grant,  a  predisposition,  a 
something  that  seems  to  invite  epilepsy  in  preference 
to  any  other  nervous  disorder.  Apparently  we 
have  only  to  study  the  tables  of  heredity  to  find  this 
true. 

In  the  same  1070  cases  just  considered  under  alcohol 
and  insanity,  a  distinct  tuberculous  history  in  the 
parents  was  found  in  101  men  and  50  women,  making 
15  per  cent,  in  the  former  and  12  per  cent,  in  the  latter, 
altogether  151,  equal  to  14  per  cent,  of  the  entire 
number. 

Account  was  taken  of  the  pulmonary  form  of  tuber- 
culosis only,  there  being  no  case  known  in  which  the 
disease  affected  the  central  nervous  system,  or  its 
meninges. 

This  percentage  seems  extraordinarily  high,  stand- 
ing second  to  epilepsy  itself,  in  which  the  percentage 
was  16,  and  next  to  alcohol,  in  which  it  was  15,  and 


70  ETIOLOGY. 

it  can  only  be  accounted  for  in  this  way :  Tuberculosis 
in  the  parents  either  predisposes  to  epilepsy  in  the 
offspring,  or  it  is  so  common  as  to  make  it  appear 
influential  when  it  may  be  only  an  incidental  affection. 
Let  us  note  the  opinion  of  others  in  this  respect: 

"It  has  been  claimed,"  says  Hare,  "by  those  who 
ought  to  know,  that  a  family  history  of  phthisis  is  a 
cause  of  epilepsy."  He  adds  that  such  a  belief  exists 
among  both  English  and  American  authors,  and  quotes 
Hamilton  as  having  230  cases  in  a  series  of  980, 
"  phthisically  inclined." 

Doubt,  however,  is  cast  over  the  entire  statement 
because  he  says  that  Hamilton's  practice  was  among 
"  a  depraved,  half -starved  class  in  a  great  city  in  which 
consumption  and  epilepsy  might  well  walk  hand  in 
hand." 

Nothnagel  and  Gowers  assert  that  phthisis  does  not 
influence  the  production  of  the  disease,  but  that  they 
are  simply  associated  in  the  same  individual. 

"Phthisis,"  says  Gowers,  "was  once  thought  to  be 
connected  with  the  disease  by  some  hereditary  mechan- 
ism, and  the  cases  of  phthisis  to  be  heard  of  in  the 
families  of  epileptics  are  many.  But  the  ratio  is  not 
found  to  be  larger  than  in  the  families  of  those  who 
are  not  epileptics,  and  an  investigation  from  the  side 
of  phthisis  clearly  showed  that  the  apparent  connection 
was  due  to  the  frequency  of  phthisis." 

My  own  opinion  is  that  phthisis  may  grant  a  pre- 
disposition to  some  forms  of  epilepsy.  If  there  is 
well-marked  phthisis  in  the  parent  at  the  time  of  con- 
ception, there  seems  to  be  no  reason  why  a  general 
tendency  to  disease  may  not  be  given  the  child. 

From  studies  made  by  Ballantyne  in  his  most  admir- 
able work  on  "Antenatal  Pathology  and  Hygiene," 
1902,  pages  206  to  216,  the  author's  views  would  seem 
not  only  to  be  entirely  within  reason,  but  to  embrace  a 
scientific  fact,  for  Ballantyne  collects  much  evidence 


HEREDITY.  71 

to  show  the  existence  of  fetal  tuberculosis,  and  we 
have  only  to  add  to  the  inherited  fatality  which  under- 
mines the  entire  stamina  a  sufficiently  powerful  ex- 
citing cause  in  order  to  develop  definite  diseases  of 
the  brain,  foremost  among  them  being  epilepsy. 


THE  INFLUENCE  OF  DIFFERENT  HEREDITARY  FACTORS  ON  THE  AGE 
AT  ONSET  OF  EPILEPSY. 

It  is  difficult  to  obtain  data  completely  reliable  on 
this  point,  but  we  are  able  to  present  the  results  of 
careful  study  along  this  line  in  12 17  out  of  1300  cases. 

The  average  age  for  the  beginning  of  the  epilepsy 
in  this  number  was  12.36  years.  Taking  574  cases 
with  neuropathic  heredity  in  which  the  age  was 
stated,  the  average  age  at  onset  was  11.22  years. 
Leaving  these  last-named  cases  out  of  consideration 
and  taking  the  cases  without  such  heredity,  the  aver- 
age age  at  onset  was  13.26.  Taking  the  cases  with 
alcoholic  heredity,  the  age  at  onset  was  10.8  years. 
The  same  average  occurred  in  cases  where  insanity 
was  noted  in  the  history.  The  average  age  at  onset 
in  the  cases  with  epileptic  family  histories  was  10.17 
years. 

The  combination  of  alcoholism  and  epilepsy  in  the 
history  brings  the  average  age  at  the  beginning  of  the 
disease  down  to  9.9  years. 

The  lowest  average  age  at  onset  was  found  in  cases 
which  had  a  combination  of  alcoholism,  epilepsy,  and 
insanity  in  the  history.  There  were  six  cases  of  the 
kind — too  few  on  which  to  base  any  conclusion — but 
the  average  for  these  was  9.5  years.  These  figures 
prove  that  heredity  influences  the  age  at  onset,  and 
also  tend  to  show  that,  as  a  rule,  the  more  unfavorable 
the  heredity,  the  lower  the  age  at  onset. 

As  a  further  illustration  of  the  influences  of  heredity 
on  the  age  at  the  beginning  of  the  disease,  it  may  be 
stated  that,  while  20  per  cent,  of  the  total  number  of 


72  ETIOLOGY. 

cases  and  17  per  cent,  of  the  cases  with  a  neuropathic 
heredity  history  began  during  the  first  three  years  of 
life,  over  25  per  cent,  of  the  cases  showing  neuropathic 
heredity  began  during  the  same  period.  During  the 
first  ten  years  of  life  46  per  cent,  of  all  the  cases  began, 
43  per  cent,  of  those  without  neuropathic  history  and 
50  per  cent,  of  those  with  such  history  having  begun 
during  this  period. 

Between  the  ages  of  ten  and  twenty  years  there  was 
no  difference.  Thirty-eight  per  cent,  of  the  total  num- 
ber of  cases,  and  39  per  cent,  of  all  cases  with  or  with- 
out neuropathic  history,  began  at  the  same  period. 
Eighty-four  per  cent,  of  the  total  number  began 
during  the  first  twenty  years;  82  per  cent,  of  cases  in 
which  neuropathic  history  was  denied  or  lacking,  and 
89  per  cent,  in  which  such  history  was  found,  began 
during  this  period. 

Consanguinity. — I  do  not  recall  ever  having  seen 
a  case  in  which  epilepsy  could  fairly  be  ascribed  to 
the  intermarriage  of  blood  relations  alone. 

Gowers  states  that  although  consanguinity  of  parents 
intensifies  the  family  habit,  there  is  no  evidence  that 
it  has  any  influence  in  producing  the  disease. 

I  am  aware  that  statistics  collected  by  some 
authors  in  Continental  Europe,  particularly  by  Bemis 
as  mentioned  by  Hare,  appear  to  show  that  such 
marriages  are  more  common  in  that  country  than  in 
this,  and  that  the  results  are  most  unsatisfactory  from 
a  health  point  of  view. 

Syphilis. — There  is  no  more  deplorable  fact  in  medi- 
cine than  the  transmission  of  syphilis  from  parent  to 
child.  It  is  most  often  handed  down  by  the  father 
(Holt,  Jacobi,  Rotch,  Koplik).  A  physician  consulted 
me  about  his  epileptic  child,  a  boy  of  eight  years, 
whose  disease  the  father  was  convinced  was  due  to 
constitutional  syphilis  transmitted  from  himself. 

Ballantyne  feels  that  Fournier  does  not  state  the 


IMMEDIATE  CAUSES  ACTIVE  IN  EARLIER  YEARS.       73 

case  too  strongly  when  he  says:  "  Syphilis  is  the  essen- 
tial murderer  of  those  young  in  years ;  it  is  the  verita- 
ble tomb  of  infants;  it  is  the  cause  of  death  before 
birth,  at  the  moment  of  birth,  after  birth,  within  the 
first  week,  or  it  may  await  the  first  year.  Syphilis, 
alcoholism,  and  tuberculosis  constitute  the  triad  of 
the  contemporaries." 

I  am  unable  to  present  figures  that  indicate  the 
frequency  with  which  inherited  syphilis  predisposes  to 
epilepsy,  or  causes  it  in  any  form,  essential  or  unessen- 
tial, and  must  be  content  to  state  that  its  power  in 
either  of  these  directions  must  occasionally  be  reckoned 
with. 

The  writer  has  under  his  care  at  this  time  a  boy  of 
seven  years  whose  epilepsy  developed  under  the  stress 
of  the  second  dentition,  who  was  delicate  and  sickly 
from  his  birth,  and  whose  father — a  man  of  intelligence 
and  position — advanced  the  idea  of  the  cause  of  the 
boy's  malady  by  confessing  to  syphilis  in  himself  when 
the  boy  was  born.  The  cause  was  further  verified  by 
the  improvement  the  patient  made  under  anti-syphil- 
itic treatment. 

A  colleague  of  the  writer's  reported  to  him  a  case 
almost  identical  with  the  above. 

Other  predisposing  causes  include  rheumatism, 
scrofula,  rickets,  constitutional  anemia,  gout,  cancer, 
parental  intoxication  at  the  time  of  conception  by 
such  drugs  as  morphin  and  lead,  diabetes,  possibly 
chorea,  and  organic  degeneration  isolated  in  the  ovaries 
and  testes. 

THE    IMMEDIATE    CAUSES    MOST    ACTIVE    DURING    THE 
EARLIER  YEARS. 

Adhering  to  the  group  division  under  Causes,  given 

on  page  31,  we  come  now  to  study  the  more  active 

as    distinguished    from    the    predisposing    causes    of 

epilepsy  in  infantile  life,  a  period  we  may  for  practical 


74  ETIOLOGY. 

purposes  arbitrarily  assume  to  terminate  at  the  end 
of  the  third  year. 

These  causes  are  numerous  and  include,  in  addition 
to  others,  to  be  specified  in  greater  detail  later  on, 
those  of  a  pre-natal  or  congenital  order,  birth  accidents, 
the  specific  fevers  and  their  sequela?,  the  stress  of  the 
first  dentition,  and  possibly  in  rare  instances,  shock 
from  fright,  though  the  latter  is  less  a  factor  here 
than  later  on  in  the  childhood  period. 

And  just  here  let  me  state  the  distinction  held  to 
exist  between  congenital  or  pre-natal  causes,  and  those 
assigned  to  heredity.  By  the  former  is  meant  a  cause 
that  existed  in  the  child  at  birth,  that  originated 
during  intra-uterine  life  or  was  acquired  at  birth,  no 
part  of  which  was  given  the  child  as  the  result  of  some 
constitutional  imperfection  in  the  parents. 

By  the  latter  is  meant  a  cause  born  with  the  child 
and  acquired  as  the  result  of  some  constitutional  im- 
perfection in  the  parents. 

Cerebral  Palsies. — Unquestionably  one  of  the  greatest 
single  causes  at  this  early  age  are  the  brain  palsies 
which  show  themselves  in  the  form  of  hemiplegia, 
diplegia,  or  paraplegia,  the  former  being  far  more 
common  than  the  two  latter  combined. 

In  1070  patients  of  all  ages  at  the  Craig  Colony, 
many  of  them  so  far  advanced  in  age  as  to  have  lost 
all  but  the  faintest  trace  of  the  results  of  a  cerebral 
hemorrhage  that  occurred  in  infancy,  116  or  11  per 
cent,  had  epilepsy  as  the  result  of  this  cause,  67  of 
the  116  being  men  and  49  women;  as  there  was  no 
discrepancy  in  sex,  the  seeming  inequality  is  due  to 
the  fact  that  more  men  than  women  were  studied. 

The  seat  of  the  lesion  in  these  cases  is  in  the  hemi- 
sphere of  the  brain,  involving  the  central  motor 
neurons,  and  that  part  of  the  motor  tract  which  ex- 
tends from  the  brain  cortex  as  far  as  the  anterior 
horn.     This  makes  such  palsies  cortico-spinal,  in  con- 


Plate 


Showing  the  attitude  and  deformity  in  left  hemiplegia  associated  with 
epilepsy.  The  perpetuation  of  the  convulsions  in  these  cases  is  often  due 
to  the  'cerebral  hemorrhage  that  establishes  the  paralysis. 


IMMEDIATE  CAUSES  ACTIVE  IN  EARLIER  YEARS.        75 

tradistinction  to  those  due  to  disorders  of  the  neuro- 
spinal  neurons,  which  give  rise  to  the  forms  of  infantile 
spinal  paralysis  without  involvement  of  the  brain. 

Cerebral  palsies  occur  after  the  third  year,  but  the 
vast  majority  of  them  occur  before  that  time,  while 
a  third  of  them  are  congenital.  When  the  latter  is 
the  case,  it  may  be  due  to  an  injury  received  by  the 
mother  during  pregnancy,  or  to  an  injury  inflicted  on 
the  child  through  forceps,  or  to  some  other  accident 
attendant  upon  the  parturition  period. 

It  is  a  well-known  fact  that  during  the  first  two 
months  of  life  reflex  action  is  insufficiently  developed 
and  convulsions  which  appear  in  that  time  are  almost 
always  primarily  cerebral  and  due  to  hemorrhage. 

It  is  difficult  to  over-estimate  the  damage  that  may 
follow  the  minutest  hemorrhage,  especially  when  it 
occurs  at  a  period  marked  by  such  active  growth 
and  development  on  the  part  of  the  brain,  as  in 
childhood.* 

It  is  timely  at  this  point  to  impress  the  importance 
of  searching  examinations  for  evidences  of  cerebral 
hemorrhages  in  every  case  that  comes  before  us. 

The  writer  has  found  more  than  once  distinct  evi- 
dences of  a  former  hemorrhage  in  cases  in  which  the 
true  cause  of  the  disease  had  been  entirely  overlooked. 

In  such  cases  hearsay  evidence  should  never  be 
accepted.  It  is  always  best  to  strip  the  patient;  ex- 
amine all  reflexes,  superficial  and  deep;  test  the  mus- 
cular power  and  cutaneous  sensation;  observe  the 
manner  in  which  the  patient  holds  or  carries  himself, 

*  The  writer  recalls  the  impression  this  first  made  on  him  when  listening 
to  a  lecture  on  the  results  of  hemorrhage  by  Virchow  some  years  ago. 

Eight  or  ten  specimens  were  exhibited  to  illustrate  the  damage  done  to 
brain  tissue  through  minute  extravasations  almost  imperceptible  to  any 
but  a  well-trained  eye. 

A  week  later  I  asked  Hughlings-Jackson  what  he  thought  might  eventu- 
ally be  found  to  be  the  cause  of  most  cases  of  "idiopathic  epilepsy,"  and 
he  promptly  replied,  "Small  hemorrhages  in  the  brain." 


76  ETIOLOGY. 

and  note  his  gait;  in  short,  leave  no  stone  unturned 
that  may  reveal  the  presence  of  the  results  of  a  former 
hemorrhage  in  the  brain. 

If  the  patient  can  be  seen  immediately  after  an 
attack,  or  a  series  of  attacks,  local  muscular  weak- 
nesses will  declare  themselves  then  better  than  during 
the  inter-paroxysmal  period,  for  the  attack  serves  to 
further  deplete,  and  even  at  times  temporarily  destroy, 
the  foci  of  muscular  innervation  in  the  brain. 

For  some  time  I  had  under  my  care  a  young  girl 
whose  epilepsy  followed  a  grave  colitis  at  the  age  of 
six  years;  the  severe  convulsions  occurring  at  that 
time  produced  a  cerebral  hemorrhage  which  furnished 
a  permanent  basis  for  epilepsy.  Ordinarily  she  had 
some  drooping  of  the  left  shoulder  only,  but  after  a 
series  of  attacks  the  left  leg  and  arm  suffered  an  ex- 
haustion paralysis  that  lasted  several  days. 

Such  conditions  constitute  true  exhaustion  paralysis, 
so  well  studied  and  described  by  Clark,*  and  which 
will  be  referred  to  separately  when  we  come  to  study 
more  at  length  the  physical  effects  of  seizures  of  dif- 
ferent types. 

The  following  cases  clearly  illustrate  the  action  of 
the  cause  under  discussion. 

W.  B.  (115 7)  first  came  under  observation  when  he 
was  ten  years  old.  He  had  been  epileptic  since  the  age 
of  nine  months.  His  mother  was  healthy,  his  father 
"intemperate."  Birth  was  normal  and  the  child 
apparently  was  strong  and  robust.  He  had  "pro- 
longed fits  of  crying  when  a  baby."  The  first  con- 
vulsion occurred  at  nine  months  and  "lasted  ten 
hours,  and  was  due  to  eating  green  berries."  "The 
first  fit,"  the  parents  stated  (which  was  really  a  serial 
attack),  "settled  in  his  right  side."  The  convulsions 
that,  followed  appeared  about  once  a  month  at  first. 
He  began  to  walk  at  fourteen  months,  at  which  time 
"right  hemiplegia  was  still  marked."     There  was  total 

*  "Archives  of  Neurology  and  Psycho-pathology,"  Vol.  11,  1899. 


Plate  5. 


Right  hemiplegia,  especially  involving  the  foot,  occurring  at  the  age 
of  one  year.  Epileptic  convulsions  commenced  soon  after.  Note  flat 
plantar  arch  left  foot.     Right  hand  also  paralyzed. 


IMMEDIATE  CAUSES  ACTIVE  IN  EARLIER  YEARS.       77 

lack  of  mental  development,  and  his  present  condition, 
at  eleven  years  of  age,  is  that  of  an  epileptic  idiot, 
with  paralysis  of  one  side. 

H.  S.  (994)  was  born  of  middle-aged  parents.  For- 
ceps delivery.  Father  healthy;  mother,  maternal 
aunt,  and  sister  are  epileptic.  He  had  an  attack  of 
meningitis  at  eight  months,  during  which  "convul- 
sions lasted  three  days,  followed  by  left  hemiplegia." 
The  patient  was  fourth  in  line  of  birth  in  a  family 
of  seven,  all  of  whom,  save  himself,  are  dead,  four 
having  been  still-born.  The  patient  is  now  ten  years 
old.  His  attacks  occur  about  once  a  week,  and  he 
has  the  mind  of  an  imbecile. 

J.  R.  (980)  was  born  of  parents  past  middle  age, 
both  of  whom  were  ' '  markedly  tuberculous ' '  at  the 
time.  Dentition  began  at  fourteen  months  and  the 
process  was  difficult.  He  had  "diphtheria  at  thirteen 
months,  meningitis  at  sixteen  months,  scarlet  fever 
at  four  years,  and  whooping-cough  at  five  years." 
First,  convulsions  came  "just  after  the  meningitis  and 
lasted  forty-eight  hours."  After  that  they  came  rap- 
idly, two  or  three  a  day.  The  functions  of  the  right 
eye  and  the  right  ear  were  defective,  and  the  entire 
right  side  was  paralyzed.  This  condition  followed 
the  first  convulsions. 

These  three  cases  are  typical  of  a  distinct  variety 
that  is  unfortunately  too  common. 

While  it  is  the  convulsion  that  brings  on  the  hemor- 
rhage, which  in  time  causes  the  epilepsy,  there  must 
be  other  causes  back  of  it  for  the  convulsion,  and  these 
are  numerous. 

In  the  case  of  W.  B.  the  cause  was  undoubtedly 
indigestion,  due  to  things  wholly  improper  for  food 
at  the  age  of  nine  months,  though  the  convulsion 
might  never  have  occurred  had  there  not  been  a  pre- 
disposition to  nervous  diseases  acquired  by  the  child 
as  the  result  of  alcoholism  in  the  father. 

In  the  case  of  H.  S.  the  convulsion  was  again  only 
an  exciting  cause  acting  on  a  strongly  marked  in- 
herited inclination  to  some  nervous  disease,  while  it 


78  ETIOLOGY. 

was  excited  to  action  by  an  attack  of  meningitis — the 
primary  cause  being  the  inherited  predisposition;  the 
secondary,  the  meningitis;  the  third,  the  convulsion 
that  laid  a  substantial  organic  foundation  for  a  con- 
tinuance of  the  fits. 

The  third  case,  that  of  J.  R.,  is  almost  similar  to 
the  one  just  given;  the  remote  cause  here  being  the 
tuberculosis  in  the  parents;  the  secondary  cause,  the 
meningitis  that  occurred  at  sixteen  months;  the  final 
and  lasting  cause,  the  convulsions  that  followed  this. 

The  prevention  of  such  cases  as  these  and  their 
treatment  at  a  time  when  the  convulsive  habit — when 
the  "recurring  tendency  constitutes  the  disease,"  as 
Gowers  says — may  possibly  be  checked  before  epi- 
lepsy is  fully  established,  are  matters  of  vital  impor- 
tance, fitted  to  engage  the  attention  of  the  general 
practitioner  who  comes  into  contact  with  them  first. 

Dentition. — While  it  is  true  that  the  stress  due  to 
the  irritation  of  difficult  dentition  is  capable  of  exciting 
convulsions  which  may  sooner  or  later  pass  into  true 
epilepsy,  it  is  equally  true  that  it  is  impossible  to  reach 
a  conclusion  as  to  even  the  approximate  number  of 
cases  so  caused,  for  the  reason  that  the  period  of 
dentition  is  replete  with  other  causes  actively  produc- 
tive of  the  same  results. 

The  period  of  dentition  begins  about  the  middle  of 
intra-uterine  life  and  ends,  visibly,  first  at  about  the 
thirtieth  month,  and  secondly,  about  the  twelfth  year. 

It  has  long  been  the  writer's  belief  that  dentition 
when  severe,  and  acting  on  an  organism  that  bears  the 
impress  of  transmitted  weaknesses  of  a  necessary  kind, 
plays  an  important  role  in  the  production  of  epilepsy 
in  early  life. 

Let  us  understand,  however,  that  a  single  convulsion 
caused  by  the  stress  of  abnormal  dentition  is  not 
epilepsy,  though  it  may  be  perilously  near  it  in  patients 
possessing  a  depraved  constitution,  and  that  genuine 


Plate  6. 


_  Left  hemiplegia  in  a  boy  of  nineteen  years.  The  paralysis  commenced 
in  the  left  thumb  at  two  months,  extending  slowly  until  the  tenth  month, 
when  the  entire  left  side  was  affected.  Epileptic  convulsions  developed 
two  months  after  onset  of  paralysis. 


IMMEDIATE  CAUSES  ACTIVE  IN  EARLIER  YEARS.       79 

epilepsy  should  be  said  to  exist  only  when  the  convul- 
sive habit  has  become  firmly  established.  But  even 
so,  the  dentition,  the  active  factor  which  causes  the 
first  convulsion,  is  after  all  the  real  cause  of  the  disease. 

It  is  interesting  to  note  the  views  of  other  writers  on 
this  point. 

Gowers  says:  "A  considerable  number  of  cases  of 
epilepsy  date  from  infantile  convulsions.  In  many  of 
them  the  first  fits  occur  during  retarded  dentition, 
commonly  with  other  indications  of  the  state  called 
rickets,  as  definite  convulsions,  or  as  minor  attacks, 
these  persisting  to  puberty,  after  which  they  become 
definitely  epileptiform. 

'  'This  suggests  that  the  early  convulsions  produce 
a  lasting  modification  of  the  brain,  one  facilitating  the 
tendency  to  discharge  at  the  developmental  epoch. 

"In  about  a  tenth  of  the  total  number  of  cases  of 
epilepsy  some  such  influence  must  be  ascribed  to 
infantile  convulsions.  The  popular  connection  of 
these  fits  with  the  process  of  teething  has  probably 
very  slight  foundation  in  fact ;  a  slight  local  irritation 
may  have  an  exciting  influence,  but  the  chief  factor 
is  the  general  retardation  of  development." 

"Epilepsy,"  says  Fere,  "may  appear  in  connection 
with  dental  disturbance.  The  frequency  of  convul- 
sions in  young  infants  during  dentition  is  well  known. 
The  opinions  of  physicians  who  confine  their  attention 
entirely  to  diseases  of  children,  and  who  have  had  a 
large  experience  along  this  line,  are  perhaps  as  valuable 
on  this  point  as  are  the  opinions  of  neurologists." 

L.  Emmet  Holt  *  deals  in  part  with  the  subject  as 
follows : 

"Although  I  strongly  believe  that  the  importance 
of  dentition  as  an  etiologic  factor  in  disease  has  been 
in  the  past  greatly  exaggerated,  and  although  I  have 
formerly  held  the  opinion  that  simple  dentition  did 

*  "Diseases  of  Infancy  and  Childhood,"  1900,  p.  243. 


80  ETIOLOGY. 

not  and  could  not  produce  symptoms,  within  the  past 
four  years  I  have  been  compelled  to  change  my  opinion 
upon  the  subject,  and  I  am  now  willing  to  admit  that 
dentition  may  produce  reflex  symptoms,  some  even 
of  quite  an  alarming  character. 

"  Speaking  from  impressions  and  not  from  statistics, 
I  should  say  that  in  my  own  experience  about  half 
of  the  healthy  children  cut  their  teeth  without  any 
visible  symptoms,  local  or  general." 

Holt  then  enumerates  some  of  the  symptoms  pro- 
duced by  difficult  dentition,  including  wakefulness  at 
night;  fretfulness  during  the  day;  loss  of  appetite; 
catarrhal  stomatitis;  constipation  or  diarrhea;  fever, 
in  ordinary  cases  running  up  to  ioi°  F.,  in  extreme 
cases  to  1040  F.,  the  latter  occurring  in  delicate  or 
rachitic  children;  and  severe  attacks  of  acute  indiges- 
tion, finally  adding  : ' '  Convulsions  due  to  dentition  I 
have  never  seen,  yet  I  do  not  doubt  that  they  may 
occur  in  rachitic  children." 

J.  Lewis  Smith  in  his  classical  work  *  says : 

"Among  the  more  common  pathologic  results  of 
difficult  dentition  are  certain  affections  referable  to 
the  cerebrospinal  system.  Eclampsia  is  one  of  the 
admitted  results.  Barrier  attributes  convulsions  in 
the  teething  infant  to  excitement  of  the  nervous  system 
arising  from  pain  which  is  felt  in  the  gums  and  to  a 
determination  of  blood  in  the  dental  apparatus,  in 
which  reflex  the  vascular  system  of  the  head  partici- 
pates. Difficult  dentition  must  be  considered  not  so 
frequently  a  direct  as  perhaps  a  predisposing  cause, 
producing  a  sensitive  state  of  the  nervous  system 
or  possibly  an  afflux  of  blood  to  the  head,  and  which 
by  an  additional  trivial  stimulus  ends  in  convul- 
sions." 

This  author  also  mentions  a  case  in  which  the  ap- 
pearance of  "five  incisor  teeth  in  two  weeks  caused 

*  "Diseases  of  Children,"  1896,  p.  692. 


IMMEDIATE  CAUSES  ACTIVE  IN  EARLIER  YEARS.       8l 

two  attacks  of  eclampsia,  all  other  causes  being  strictly 
omitted." 

"Epilepsy,"  says  Voisin,*  "is  above  all  the  malady 
of  infancy.  It  makes  its  first  appearance  at  birth, 
but  generally  it  is  at  the  moment  of  dentition  that 
the  first  manifestations  present  themselves.  In  these 
cases  dentition  is  the  'touchstone'  of  the  hereditary 
predisposition." 

In  a  study  of  the  causes  of  insanity  in  children  by 
the  writer,  which  appeared  in  the  "Medical  News" 
in  1894,  may  be  found  a  number  of  opinions  on  the 
mental  effects  of  dentition,  a  few  of  which  are  repro- 
duced in  substance  here. 

Dr.  Graeme  M.  Hammond  had  "records  of  several 
cases  in  which  convulsions  due  to  dentition  were 
followed  by  true  epileptic  convulsions." 

Dr.  F.  Peterson  could  "recall  a  number  of  cases  in 
which  epilepsy  was  due  to  the  convulsions  of  den- 
tition." 

Dr.  T.  S.  Clouston — the  well-known  alienist,  super- 
intendent of  the  Royal  Morningside  Asylum  at  Edin- 
burgh—said, "  I  have  seen  the  convulsions  of  dentition 
followed  by  prolonged  delirium  ending  in  idiocy,  or 
in  true  epilepsy,  or  insanity  of  adolescence." 

Dr.  G.  Alder  Blumer  thought  there  was  "  no  such  thing 
as  a  convulsion  due  to  dentition  pure  and  simple." 

Dr.  Jacobi  wrote:  "Every  convulsion,  ever  so 
slight  or  short,  may  produce  cerebral  hemorrhage, 
with  all  its  possible  results — epilepsy,  idiocy,  paralysis, 
and  insanity. ' '  Apparently  he  did  not  mean  that  the 
convulsions  referred  to  were  due  to  dentition,!  but 
did  admit,  as  stated  by  the  writer,  "that  the  spasms 
and  convulsions  of  infancy  are  serious  manifestations, 
and  if  allowed  to  go  unchecked  may  lead  to  explosions 
of  genuine  epilepsy  and  later  on  to  insanity." 

*  "L'epilepsie,"  1897,  p.  23. 

t  "Causes  of  Epilepsy  in  the  Young,"  "Medical  News,"  Dec.  13,  1902. 
6 


82  ETIOLOGY. 

In  eighteen  cases  of  epilepsy  that  have  come  under 
my  observation  in  which  the  disease  began  between 
the  sixth  month  and  the  end  of  the  second  year,  the 
cause  was  ascribed  to  "teething,"  or  to  "dentition 
and  indigestion' ' ;  and  it  was  particularly  noted  that 
the  family  history  in  the  majority  of  these  cases  was 
bad;  in  some  of  them  extremely  so. 

Summing  up  the  facts  in  the  case,  it  seems  reason- 
able to  hold  that  difficult  dentition,  when  acting  on 
an  organism  suffering  from  inherited  constitutional 
diseases,  like  rickets,  tuberculosis,  alcoholism,  epilepsy, 
insanity,  and  the  like,  excites  reflex  convulsions  that 
in  time  degenerate  into  true  epilepsy. 

The  ratio  of  cases  in  which  simple  convulsions  may 
pass  into  epilepsy  is  governed  entirely  by  the  original 
stamina  of  the  patient  and  the  vigor  with  which  he  is 
treated  immediately  after  convulsions  appear. 

Points  worth  our  serious  attention  are  the  disturb- 
ances of  digestion ;  in  fact,  the  disorders  of  the  entire 
alimentary  canal,  so  prone  to  occur  in  young  children 
at  this  age,  and  which  may  greatly  aggravate  the  effects 
of  difficult  dentition,  or  themselves  cause  convulsions, 
through  forms  of  auto-intoxication,  erroneously  as- 
cribed to  carious  irritation. 

THE  INFECTIOUS  FEVERS. 

We  note  occasional  references  in  medical  literature 
to  the  infectious  fevers  as  causes  of  epilepsy,  although 
we  do  not  find  any  mention  made  as  to  the  probable 
frequency  of  cases  due  to  such  causes. 

Scarlet  Fever. — This  type  of  fever  seems  to  lead  to 
epileptiform  convulsions  at  first  and  later  on  to  true 
epilepsy  more  often  than  any  other.  In  a  series  of 
1323  cases,  814  men  and  509  women,  it  was  found  to 
be  the- cause  in  25  cases,  18  of  which  were  men  and  7 
women,  the  proportion  between  the  two  sexes  being 
approximately  the  same. 


IMMEDIATE  CAUSES  ACTIVE  IN  EARLIER  YEARS.       83 

The  epilepsies  due  to  this  cause  invariably  develop 
during  the  essential  epileptic  age,  i.  e.,  before  the 
twentieth  year;  while  the  greater  number  of  them 
appear  between  the  sixth  and  fifteenth  year,  a  period 
that  embraces  the  second  dentition  and  the  epoch  of 
puberty,  both  of  which  strongly  aid  in  the  establish- 
ment of  any  nervous  disorder  in  which  heredity  plays 
an  important  rdle. 

It  also  further  appears  that  in  the  majority  of  cases 
it  is  not  the  fever  itself  that  excites  the  convulsions, 
since  they  do  not  generally  come  on  until  this  has 
subsided,  but  the  after-effects  of  the  disease,  chiefly 
in  the  way  of  scarlatinous  nephritis. 

When  the  convulsions  due  to  this  condition  change 
from  general  to  unilateral,  when  they  have  been  vio- 
lent, or  appear  in  series,  it  is  safe  to  assume  that  the 
change  in  type  is  due  either  to  a  cerebral  hemorrhage, 
to  a  thrombosis,  or  to  a  marked  exhaustion  paralysis, 
the  results  of  the  former  being  ineradicable,  the  latter 
in  some  cases  susceptible  of  removal  entirely,  though 
not  always  with  the  result  of  checking  the  attacks. 

Another  peculiarity  of  such  attacks  is  this :  When 
a  child  has  scarlet  fever,  at  seven  or  eight  years  of 
age,  followed  by  nephritis  and  convulsions,  the  con- 
vulsions may  disappear  entirely  in  a  short  while  and 
remain  absent  for  years,  to  recur  under  some  provo- 
cation that  seems  to  excite  the  original  cause  into 
action. 

An  illustration  of  this  peculiarity  is  shown  in  the 
following  case : 

E.  B.  G.,  whose  father  had  rheumatism  and  died  of 
"congestion  of  the  brain"  at  fifty-seven,  had  a  severe 
attack  of  scarlet  fever  when  he  was  eight  years  old, 
followed  by  convulsions  which  occurred  at  first  daily, 
then  about  once  a  month.  On  reaching  early  man- 
hood, the  attacks  left  him  for  seven  years,   and  he 


84  ETIOLOGY. 

made  a  trip  to  Europe  alone  during  that  time.  Then 
they  returned,  and  now,  at  the  age  of  thirty-nine, 
they  occur  from  two  to  three  weeks  apart.  His 
memory  for  recent  events  is  poor,  though  for  things 
that  happened  earlier  in  his  life  it  is  most  excel- 
lent. 

Besides  illustrating  a  type  of  the  disease  in  which 
long  remissions  occur,  it  also  illustrates  one  in  which 
the  convulsions  at  first  were  primarily  reflex — due 
to  some  disease  outside  the  brain  and  affecting  that 
organ  only  in  a  reflex  manner.  Such  cases  are  nu- 
merous. 

Prototypes  of  the  convulsions  that  appear  after  an 
attack  of  nephritis  due  to  scarlet  fever  in  childhood  are 
found  in  cases  of  uremic  convulsions  which  occur  later 
in  life,  particularly  in  B right's  disease,  when  the  age 
of  the  patient,  his  lessened  powers  of  resistance, 
associated  with  other  more  serious  things,  more  often 
combine  to  destroy  life,  although  there  may  be  cases 
in  the  very  young  in  which  urinalysis  may  fail  to 
show  uremia  as  a  cause,  in  which  event  we  must  look 
for  something  besides  the  nephritis. 

Jacobi  *  reports:  "An  example  of  this  kind  is  now 
in  my  hospital  ward,  a  child  with  nephritis  after  scar- 
latina which  ran  its  course  four  months  ago.  While 
practically  in  convalescence  he  was  taken  with  eclamp- 
tic attacks  a  few  days  ago.  As  there  was  a  daily  renal 
secretion  of  from  500  c.c.  to  600  c.c,  a  percentage  of 
more  than  2  of  urea,  and  no  indiscretion  in  his  diet, 
the  diagnosis  of  uremic  intoxication  was  out  of  the 
question.  This  obliged  us  to  inquire  into  his  past, 
when  a  history  of  several  unprovoked  convulsions  of 
an  epileptic  character  during  the  past  eighteen  months 
was  obtained." 

In  such  a  case  there  must  have  been  a  strong  pre- 
disposition to  convulsions  present,  the  irritation  of  the 

*  "Medical  News,"  Dec.  31,  1902. 


IMMEDIATE  CAUSES  ACTIVE  IN  EARLIER  YEARS.       85 

nephritis,  acting  simply  as  the  "touchstone"  that 
brought  them  to  light. 

Gowers  speaks  of  the  remarkable  influence  of  scar- 
let fever  in  causing  epilepsy,  but  doubts  that  it  does 
it  through  uremic  poisoning.  In  fact,  he  goes  so  far 
as  to  say  that  in  most  instances  any  evidence  of  such 
disease  is  lacking,  and  assumes  that  the  fits  are  due  to 
some  peculiar  effects  of  the  scarlet  fever  poison  upon 
the  nervous  system. 

In  the  opinion  of  the  writer,  fully  2  per  cent,  of  all 
cases  of  epilepsy  are  due  to  scarlet  fever,  and  we  should 
not  dispute  creditable  statements  that  seek  to  place 
the  percentage  even  higher. 

Whooping-cough. — Altogether  five  cases  of  epilepsy 
due  to  whooping-cough  have  come  under  my  obser- 
vation, making  about  a  third  of  1  per  cent,  of  the 
total  number. 

According  to  Szabo,  of  Budapest,  in  a  series  of  4591 
cases  of  pertussis,  2695  of  them  occurred  before  the 
end  of  the  third  year. 

In  view  of  the  great  frequency  and  severity  of  the 
malady,  it  seems  remarkable  that  it  is  not  more  often 
the  cause  of  epilepsy,  as  indeed  it  may  be.  It  is  not 
uncommon  for  a  child  to  die  during  a  paroxysm  of 
coughing.  The  brains  of  such  children  are  found 
engorged  with  blood.  Any  agency  that  so  greatly 
and  violently  increases  intracranial  pressure  in  per- 
sons of  feeble  stamina,  especially  children,  may  cause 
cerebral  hemorrhage  with  its  consequent  results  of 
paralysis  and  epilepsy. 

The  convulsions  that  occur  during  the  paroxysms 
of  whooping-cough  may  probably  be  ascribed  to  the 
poisonous  effects  of  the  excess  of  carbonic  acid  in 
the  blood,  due  to  a  partial  asphyxia. 

In  the  American  edition  of  Nothnagel's  "Encyclo- 
pedia of  Medicine,"  1902,  under  the  complications  of 
whooping-cough  we  find  this  statement: 


86  ETIOLOGY. 

"Eclamptic  attacks  (convulsions  externes)  are  not 
uncommon  in  children  with  an  inclination  to  convul- 
sions, or  in  those  who  manifest  symptoms  of  hydro- 
cephalus. They  occur  in  mild  forms  of  whooping- 
cough  frequently  during  teething,  yet  also  as  late  as 
the  fifth  year,  and  appear  usually  between  the  eigh- 
teenth and  thirty-fifth  day  of  the  disease. 

"According  to  some  authorities  they  take  place 
more  frequently  the  more  violent  the  coughing  at- 
tacks. They  are  ushered  in  by  excitement  or  drow- 
siness, and  often  again  by  extreme  dyspnea.  They 
occur  subsequently  to  a  paroxysm  of  coughing,  or 
they  happen  during  a  free  interval,  or  interrupt  the 
seizure,  thereby  changing  its  character,  or  causing 
the  paroxysms  to  cease  entirely." 

Sticker  describes  the  clinical  manifestations  of 
the  convulsions;  how  they  grow  in  violence  with 
each  repetition,  how  they  decrease  in  mild  cases  in 
frequency  and  severity,  until,  finally,  all  alarming 
symptoms  cease  and  the  child  gets  well. 

In  other  cases  the  convulsions  that  are  local  in  the 
beginning  become  general;  the  child  sinks  under 
prostration  and  dies  within  the  first  three  days. 
"Among  ten  children,"  he  says,  "nine  are  certainly 
doomed." 

In  those  cases  in  which  the  convulsions  come  on 
during  or  just  after  the  coughing  paroxysm,  and  when 
it  is  at  first  local  in  nature,  it  is  undoubtedly  due  to 
some  focal  irritation  in  the  brain,  like  a  slight  hemor- 
rhage, a  thrombus,  or  an  embolism. 

In  those  in  which  the  convulsions  appear  during  the 
remissions  that  separate  the  coughing  paroxysm,  it 
may  be  due,  as  before  indicated,  to  chemical  changes 
in  the  blood,  or  to  the  action  of  the  specific  poison  of 
this  disease. 

All  of  the  cases  noted  by  me  occurred  in  children 
ranging  in  age  from  six  months  to  six  years. 


IMMEDIATE  CAUSES  ACTIVE  IN  EARLIER  YEARS.       87 

A  little  girl  of  three  years  had  whooping-cough 
which  was  immediately  followed  by  spinal  meningitis, 
attended  with  convulsions  and  right  hemiplegia;  the 
convulsive  attacks  became  fixed,  and  five  years  later 
they  occurred  at  the  rate  of  from  8  to  10  a  month. 
Such  a  result  as  this  may  follow  in  any  case. 

Insolation. — -Thermic  fever  caused  the  same  number 
of  cases  that  were  due  to  whooping-cough,  namely,  4 ; 
and  we  are  unable  to  offer  a  suggestion  as  to  the  man- 
ner in  which  the  cause  acted,  unless  we  assume  that 
the  convulsions  were  induced  by  the  effects  of  high 
temperature,  or  came  from  chemical  changes  in  the 
blood. 

All  four  of  the  cases  studied  were  males;  two,  four- 
teen, one,  ten,  and  the  other  twenty-five  years  of  age. 

A  predisposing  heredity  was  present  in  three,  and 
was  extremely  marked  in  one  of  the  younger,  there 
being  epilepsy,  insanity,  and  alcoholism  in  his  family. 
The  "  father  was  an  alcoholic  and  a  suicide,  one  pater- 
nal uncle  an  idiot,  another  an  epileptic;  the  mother 
had  chorea  in  childhood,  and  hysteria  later  on.  An- 
other had  convulsions,  and  a  sister  was  an  epileptic." 

In  this  case  it  is  not  difficult  to  see  that  there  was 
ample  preparation  made  in  the  patient  by  depraved 
ancestors  to  fit  him  for  almost  any  disease,  espe- 
cially one  that  came  at  the  epoch  of  puberty,  the 
period  when  the  sunstroke  was  received.  Alcoholism 
alone  tends  to  invite  insolation,  but  this  boy  did  not 
drink,  he  only  inherited  an  instability  from  his  father, 
whose  stamina  was  always  of  a  depraved  order. 

One  of  the  cases  was  that  of  a  carpenter,  who  en- 
listed as  a  soldier  at  the  age  of  thirty- two  and  was  sent 
to  Cuba  during  the  Spanish- American  war  in  1898, 
where  he  had  a  sunstroke  followed  by  convulsions 
that  later  developed  into  epilepsy. 

The  youngest  patient,  a  boy  of  ten  years,  also  had  a 
bad  heredity ;  his  father  was  an  alcoholic  and  suffered 


88  ETIOLOGY. 

from  rheumatism ;  two  brothers  were  habitual  drunk- 
ards and  a  sister  was  an  idiot. 

Typhoid  Fever. — In  three  cases  the  cause  was 
ascribed  to  typhoid  fever.  Two  of  the  patients  were 
women  thirty-two  and  thirty-three  years  of  age; 
the  third  was  a  boy  of  four  years,  whose  family  history 
was  good,  while  that  of  both  the  women  was  unsatis- 
factory. In  the  younger  woman  it  was  said  there  had 
never  been  any  convulsions  prior  to  the  time  she  had 
typhoid  fever  at  thirty  years  of  age,  which  had  been 
followed  by  "weaknesses,"  and  later  by  true  epilepsy, 
but  this  may  be  doubted.  She  had  a  child  a  year 
after  her  marriage  at  eighteen,  who  is  now  an  epilep- 
tic, so  this  case  may  not  properly  be  ascribed  to  the 
effects  of  typhoid  fever.  About  the  other  there  seems 
to  be  no  doubt. 

A.  C.  Brown*  reports  a  case  of  Jacksonian  epilepsy 
following  an  abscess  of  the  brain  that  involved  the 
Rolandic  area  on  the  right  side.  The  author  states 
that  the  abscess  was  due  to  an  attack  of  typhoid  fever, 
the  same  pyogenic  organisms  which  caused  the  fever 
having  produced  the  abscess. 

Dide  t  reports  cases  of  epilepsy  caused  by  the  in- 
fection of  typhoid  fever;  in  some  the  convulsions 
appeared  during  the  fever,  and  were  due  to  the  direct 
action  of  the  typhoid  toxin;  while  in  others  they 
developed  after  the  fever  was  over,  constituting  in 
these  cases  paratyphoid  manifestations,  and  resulting 
remotely  from  cellular  changes  induced  in  the  nervous 
system  by  the  action  of  the  poisons  generated  in  the 
course  of  the  disease. 

Cases  have  also  been  recorded  in  which  epilepsy 
existed  in  conjunction  with  boils  and  abscesses  about 
the  scalp,  the  assumption  being  that  they  were  caused 

♦  "Edinburgh  Medical  Journal,"  Sept.,  1900. 
f  "Revue  de  medecine,"  Feb.  10,  1899,  p.  151. 


IMMEDIATE  CAUSES  ACTIVE  IN  EARLIER  YEARS.       89 

by  a  pyemic  state,  the  relief  of  which  cured  the  con- 
vulsions. 

Typhus  and  Yellow  Fever. — One  case  was  ascribed 
to  typhus,  though  the  details  are  not  clear  enough  to 
give  substantiation,  and  one  to  yellow  fever.  In  the 
latter  case,  that  of  a  sailor  who  contracted  the  disease 
in  a  tropical  country,  the  family  history  could  not  be 
obtained.  The  patient  had  no  convulsions  prior  to 
the  age  of  nineteen,  when  they  followed  the  attack 
of  yellow  fever. 

Pneumonia  was  given  as  the  cause  in  a  boy  of 
seven,  whose  family  history  was  not  good  and  whose 
mother  had  "fainting  spells." 

Grippe,  which  so  often  produces  marked  morbid 
changes  in  the  entire  nervous  system,  often  leading 
to  insanity,  was  credited  with  being  the  cause  in  one 
case,  that  of  a  man  of  fifty,  who  had  long  been  in- 
temperate and  in  whom  senile  changes  had  set  in, 
which  were  indicated  chiefly  by  the  atheromatous  con- 
dition of  his  arteries. 

Malarial  fever  was  the  cause  in  two  cases ;  one  in  a 
girl  of  three  years  who  lived  in  a  low,  miasmatic 
country,  but  whose  family  history  was  not  the  best; 
"one  paternal  aunt  was  insane,  and  one  cousin  a 
paralytic." 

It  has  been  claimed  by  eminent  writers  that  malaria 
is  not  only  capable  of  causing  epilepsy,  but  that  the 
convulsive  chills,  common  to  the  malady  in  hot  coun- 
tries, are  sometimes  substituted  for  the  epileptic 
paroxysm,  just  as  the  psychic  epileptic  equivalent  is 
believed  at  times  to  appear  as  a  substitute  for  a  real 
epileptic  convulsion. 

In  the  second  case  the  subject,  a  man  now  thirty- 
seven  years  old,  stated  that  an  attack  occurred  when 
he  was  a  boy  of  four,  and  that  a  maternal  uncle  was 
an  epileptic. 


90  ETIOLOGY. 

Marandon  de  Montyel  and  Maurice  Dide  *  very 
thoroughly  investigated  the  connection  between  epi- 
lepsy and  malaria.  In  one  existing  case  of  epilepsy 
in  which  the  convulsions  had  long  been  in  abeyance, 
the  disease  became  worse  when  the  patient  con- 
tracted malaria,  while  others  "who  had  never  before 
had  a  seizure  of  any  kind  became  markedly  epileptic" 
under  recent  malarial  infection. 

In  the  latter,  however,  the  author  admits  the  pres- 
ence of  "  a  distinct  family  neuropathic  proclivity. ' ' 

In  two  cases  the  epileptic  attacks  came  on  coincident 
with  the  rise  of  temperature  due  to  the  malarial 
poisoning. 

These  writers  make  some  observations  on  the  influ- 
ence of  the  infectious  fevers  on  epilepsy,  which  will 
be  referred  to  at  greater  length  when  we  come  to 
speak  of  treatment. 

Diphtheria. — Two  cases  followed  this  disease;  one 
in  a  girl  eleven  years  old  whose  family  history  con- 
tained instances  of  alcoholism,  epilepsy,  and  rheuma- 
tism. The  girl  herself  was  of  the  lowest  possible  moral 
stamina,  yet  she  possessed  much  intelligence,  unim- 
paired by  the  disease.  Her  attacks  occurred  once  in 
from  three  to  six  months,  and  have  persisted  now  for 
ten  years. 

The  second  case  occurred  in  a  boy  of  fourteen  years, 
about  whose  ancestry  nothing  could  be  learned. 

Measles. — In  only  one  case,  that  of  a  boy  now 
fifteen  years  old,  who  had  the  first  convulsion  just 
after  an  attack  of  measles  at  six  months,  was  this 
given  as  the  cause. 

Only  one  out  of  over  1300  cases  due  to  this  cause 
seems  strikingly  low. 

Gowers  speaks  of  1 2  cases  caused  by  measles,  though 
he  fails'  to  mention  the  total  number  of  cases  studied 
in  which  the  convulsions  occurred. 

*  "Revue  de  medecine,"  Dec.  10,  1899. 


IMMEDIATE  CAUSES  ACTIVE  IN  EARLIER  YEARS.       91 

Meningitis. — Five  cases  due  to  meningitis  have  come 
under  my  care.  In  two  it  was  confined  to  the  cover- 
ings of  the  brain;  in  the  remaining  three  it  involved 
the  coverings  of  the  cord  alone. 

In  such  cases  the  convulsions  appear,  as  a  rule, 
during  the  height  of  the  disease,  and  they  are  fre- 
quently of  such  severity  as  to  cause  cerebral  hemor- 
rhages that  perpetuate  the  attacks. 

In  one  case  the  meningitis  came  on  at  the  twenty- 
second  year,  while  in  all  the  rest  it  appeared  before 
the  seventh  year. 

From  all  the  foregoing,  it  would  appear  that  any 
of  the  specific  fevers  have  the  power  of  inducing 
epilepsy,  first  causing  reflex  or  symptomatic  convul- 
sions which,  in  a  single  attack,  or  in  a  longer  time  in 
other  cases  less  favorably  constituted  to  acquire  the 
epileptic  habit,  establish  the  true  disease. 

EMOTIONAL  SHOCK. 

The  casual  student  of  the  etiology  of  epilepsy  might 
very  properly  hesitate  to  believe  that  the  disease  is 
so  often  due  to  the  results  of  emotional  shock,  as 
reliable  data  suffice  to  show. 

Fere  says  it  is  beyond  doubt  that  in  predisposed 
subjects  a  fit  may  be  immediately  provoked  by  a 
more  or  less  intense  shock  to  the  nervous  system, 
and  that  these  physical  states  are  associated  with  an 
over-excitability  which  is  very  favorable  to  the  evolu- 
tion of  convulsive  phenomena.  At  the  menstrual 
periods  these  emotions  act  even  more  powerfully  by 
reason  of  the  nervous  susceptibility  which  accompanies 
this  physiologic  condition.  The  convulsive  discharge 
may  occur  immediately  after  the  emotion  is  experi- 
enced, but  this  is  not  always  the  case. 

The  nervous  depression  succeeding  emotional  shocks 
may  last  some  time,  and  the  attack  may  supervene 
during  the  asthenic  state,  occasionally  long  after  the 


92  ETIOLOGY. 

initial  cause.  An  epilepsy  which  manifests  itself  in 
connection  with  some  fright  may  become  definitely 
established  and  the  fits  may  thereafter  appear  without 
apparent  exciting  cause. 

In  other  instances  the  attack  occurs  invariably 
when  the  same  exciting  influence  is  reapplied;  for 
instance,  the  sight  of  a  corpse,  of  a  precipice,  of  blood 
from  an  injury,  etc. 

Of  such  importance  do  I  feel  this  too  generally 
unappreciated  factor  in  the  causality  of  epilepsy  to 
be,  that  I  quote  the  following  at  length  from  Sir 
William  R.  Gowers  on  ' '  Epilepsy  and  Other  Convul- 
sive Diseases,"  1901,  p.  25: 

"Of  all  the  immediate  causes  of  epilepsy  the  most 
potent  are  psychical — -fright,  excitement,  anxiety.  To 
these  are  ascribed  more  than  a  third  of  those  in  which 
a  definite  cause  is-  given.  Of  the  three  forms  of  emo- 
tion, fright  takes  the  first  place.  The  relation  of  this 
cause  to  age  is,  however,  very  distinct.  It  is  effective 
chiefly  in  early  life,  when  emotion  is  so  readily  ex- 
cited, and  is  most  powerful  at  the  transition  from 
childhood  to  adult  life,  while  after  middle  life  it  is 
almost  inactive.  Of  173  cases  only  14  commenced 
after  thirty  years  of  age,  and  145  began  under  twenty. 
Of  these  the  majority,  102,  began  between  ten  and 
twenty,  only  43  cases  before  ten.  The  female  sex  is 
notoriously  the  more  emotional,  and  accordingly  the 
disease  results  from  fright  in  a  larger  proportion  of 
women  than  of  men,  although  the  difference  is,  per- 
haps, less  than  might  be  expected — 61  per  cent,  of 
women  and  39  per  cent,  of  men.  It  is  notorious  also 
that  this  difference  between  the  sexes  increases  as 
life  advances.  In  childhood  one  sex  is  almost  as 
emotional  as  the  other,  but  with  puberty  men  become 
far  less'  emotional  than  women.  The  influence  of 
fright  as  a  cause  of  epilepsy  is  in  strict  harmony  with 
this  fact.     Under  ten  years  of  age  the  sexes  suffer 


IMMEDIATE  CAUSES  ACTIVE  IN  EARLIER  YEARS.       93 

equally.  Between  ten  and  twenty  the  male  sex 
suffers  less  than  the  female  sex,  as  3  to  4;  between 
twenty  and  thirty,  as  3  to  13,  and  over  thirty  the  only 
cases  due  to  this  cause  occur  in  women. 

"Predisposition  usually  exists.  Hence,  in  speaking 
of  fright  as  a  cause  of  epilepsy,  it  must  be  remembered 
(as  already  stated)  that  its  effects  are  only  that  of  the 
exciting  spark. 

"The  exact  form  of  fright  varies,  of  course,  in  dif- 
ferent cases,  but  the  list  is  instructive.  In  several 
cases  the  cause  was  some  stupid  practical  joke — a 
pretended  ghost,  children  shut  up  in  dark  cupboards, 
an  alarm  of  fire,  or  burglars.  In  a  few  cases  the 
patient  had  watched  other  persons  in  fits.  Alarm 
during  severe  thunder-storms  was  another  cause.  One 
case  was  that  of  a  soldier  who  had  his  first  fit  a  few 
hours  after  being  terrified,  while  on  sentry  duty  at 
night,  by  the  unexpected  appearance  of  some  white 
goats  on  the  top  of  the  adjacent  walls  of  a  cemetery, 
which  he  mistook  for  emissaries  from  the   graves." 

The  foregoing  statements  of  this  distinguished 
physician  are  impressive.  But  I  am  unable  to  agree 
with  him  in  the  first  statement  he  makes,  namely: 
"  Of  all  the  immediate  causes  of  epilepsy  the  most 
potent  are  psychical — fright,  excitement,  anxiety." 

I  feel  that  they  play  a  large  part — one  too  gener- 
ally unrecognized — but  my  experience  in  over  1300 
cases  does  not  lead  me  to  the  conclusion  reached  by 
Gowers. 

This  author  speaks  of  173  cases  due  (apparently) 
to  this  cause,  and  I  assume  that  they  occurred 
among  the  3000  he  mentions  as  being  the  basis  of 
his  studies.  They  would  thus  constitute  a  little  over 
5^  per  cent,  of  the  total  number,  a  percentage  that 
substantially  agrees  with  that  found  by  us  in  a  close 
study  of  1323  cases. 

My  point  of  difference  with  Gowers  lies  in  the  fact 


94  ETIOLOGY. 

that  I  found  the  most  potent,  immediate,  single 
cause  of  epilepsy  to  be  the  cerebral  palsies  of  early 
life — a  distinct  physical  cause  instead  of  a  psychic  one, 
such  as  emotional  shock,  and  which  Gowers  declares 
to  be  the  most  common. 

Referring  again  to  the  same  series  of  1323  cases 
I  found  emotional  shock  or  fright  to  have  been  the 
cause  in  62,  or  5^  per  cent.  Of  these  22  were  men 
in  a  total  of  814,  and  40  were  women  in  a  total  of 
509,  being  about  3  per  cent,  among  the  former  and 
nearly  8  per  cent,  among  the  latter,  showing  the 
cause  to  be  nearly  three  times  as  active  among 
women  as  among  men. 

This  is  generally  recognized  as  being  the  case,  and 
it  is  unmistakably  due  to  the  less  stable  nervous  system 
in  women  as  compared  with  the  opposite  sex. 

During  the  first  ten  years  of  life,  there  were  14  cases 
due  to  this  cause  among  814  men,  and  15  among  509 
women,  which  demonstrates  the  greater  susceptibility 
of  the  latter  sex  even  at  this  early  age. 

Some  writers  state  there  is  no  difference  in  the  sexes 
during  the  earlier  years,  but  such  is  not  my  experience. 
During  the  second  ten  years  only  7  cases  occurred 
among  the  same  number  of  men,  whereas  there  were 
25  among  the  women.  After  twenty  there  was  one 
case  only  in  either  sex.  It  seems,  therefore,  that 
emotional  shock  most  often  leads  to  epilepsy  in  the 
female  sex,  and  is  most  apt  to  be  active  about  the  age 
of  puberty. 

It  is  also  of  interest  to  note  the  influence  of  heredity 
in  such  cases  at  the  three  age  periods  named  above. 
Under  ten  years,  some  hereditary  influence  was  pres- 
ent in  5  boys  and  not  present  in  9.  Between  ten  and 
twenty  it  was  present  in  2  and  not  present  in  3 ;  while 
it  was  not  present  in  a  single  case  after  twenty,  thus 
making  it  a  factor  in  7  cases  only  out  of  22  among 
the  men.     Under  ten  years  it  was  present  in  10  girls 


IMMEDIATE  CAUSES  ACTIVE  IN  EARLIER  YEARS.       95 

and  not  present  in  4;  between  ten  and  twenty  it  was 
present  in  14  and  not  present  in  11,  while  it  was 
noted  in  only  one  case  after  twenty  (and  that  at  the 
forty-fifth  year),  thus  making  it  a  factor  in  20  cases 
out  of  40  among  the  women. 

The  character  of  the  emotional  shock  or  fright  is 
indicated  in  part  in  the  following:  "  Fright  from  seeing 
an  escaped  lunatic";  "frightened  by  a  drunken 
father"  ;  "  fright  from  seeing  blood  from  a  cut  finger"  ; 
"from  a  dog  bite";    "from  being  chased  by  a  cow." 

As  an  illustration  of  the  type  of  case  in  which 
emotional  shock  can  produce  epilepsy,  the  following 
is  a  typical  instance: 

L.  L.  had  the  first  convulsion  when  she  was  a  girl 
of  nine  years,  due  to  seeing  an  escaped  lunatic.  She 
has  always  been  "very  emotional  and  easily  excited." 
She  had  seven  or  eight  attacks  at  first  every  twenty- 
four  hours,  which  condition  persisted  for  some  years; 
then  they  dropped  to  four  or  five  a  day  until  1896, 
when  she  was  twenty-four  years  old.  At  that  time 
they  began  to  appear  several  days  apart.  At  first 
they  were  entirely  petit  mal  in  character,  but  later 
changed  to  grand  mal  without  an  aura.  She  has  always 
fallen  in  such  a  way  as  to  injure  her  face,  having 
several  times  fractured  her  nose,  and  more  than  once 
her  lower  jaw.  If  there  ever  was  an  element  of  hysteria 
in  her  attacks,  it  disappeared  completely  years  ago, 
for  she  is  a  typical  epileptic  at  this  time,  bearing  in 
her  face  the  only  physical  signs  pathognomonic  of  the 
disease- — a  mass  of  scars  acquired  through  repeatedly 
falling  and  injuring  the  same  place — -a  part  of  the 
only  true  fades  epileptic  a. 

It  sometimes  happens  that  when  the  disease  is 
caused  through  excitation  of  the  psychic  centers,  the 
reapplication  of  the  same  form  of  excitation  will 
bring  on  an  attack.  The  writer  has  knowledge 
of  a  girl,  now  fourteen  years  old,  in  whom  the  disease 


96  ETIOLOGY. 

appeared  when  she  was  twelve,  and  was  caused  through 
fright  on  hearing  the  fire  alarm,  and  seeing  the  fire- 
engines  go  by  one  night.  While  under  my  care  there 
were  two  occasions  when  she  heard  similar  alarms, 
and  each  time  she  had  an  attack  just  as  she  rushed  to 
the  window  to  watch  the  preparations  for  putting 
out  the  fire. 

This  is  not  only  reasonable,  but  logical,  as  well  as 
psychologic,  for  the  unconscious  association  of  ideas 
and  the  results  they  produce  are  as  definite  in  action 
as  it  is  possible  for  memory  associations  to  ever  be. 

A  gentleman  who  sat  in  Ford's  Theatre  in  Washing- 
ton the  night  Lincoln  was  assassinated  saw  the  assassin 
enter  the  box  in  which  the  President  sat;  he  saw  the 
flash  of  the  pistol  and  the  confusion  that  followed. 
-In  the  next  row  of  chairs  in  front  of  him  sat  a  lady  on 
whose  corsage  was  pinned  a  large  bunch  of  heliotrope, 
a  flower  of  intense  perfume.  He  caught  a  whiff  of 
the  odor  of  this  flower  just  as  he  saw  the  flash  from 
the  pistol  and  heard  the  noise,  and  for  thirty  years 
after,  when  he  told  me  the  story,  he  never  smelled 
the  odor  of  heliotrope  without  seeing  the  whole  tragic 
scene  reenacted  just  as  it  occurred  before  him  that 
night. 

So  it  is  that  the  sensory  stimulation  of  any  center 
or  faculty  that  is  organized  into  a  definite  action  may 
be  produced  indefinitely  under  the  reapplication  of 
the  same  or  similar  causes. 

"There  is,"  says  Thomas  Watson  in  his  classic 
work  on  "The  Practice  of  Physic,"  "yet  another  very 
singular  occasional  cause  of  epilepsy  that  deserves 
to  be  mentioned,  namely,  the  sight  of  a  person  in  a 
fit  of  that  disease." 

This  distinguished  writer  states  that  this  fact  has 
been  noted  time  and  again ;  that  patients  who 
already  have  the  malady  will  fall  in  a  convulsion  at 
the  sight  of  another  one;    that  those  not  previously 


IMMEDIATE  CAUSES  ACTIVE  IN  EARLIER  YEARS.       97 

affected  may  acquire  the  disease  in  this  way ;  and  even 
that  the  disease  will  "now  and  then  run  through  a 
boarding-school  or  through  the  ward  of  a  hospital." 
He  also  cites  the  case  of  a  young  man,  employed  in 
the  care  of  an  epileptic  suffering  frequent  and  violent 
attacks,  who  himself  became  a  victim  of  the  disease 
at  the  end  of  seven  weeks. 

Watson  speaks  of  the  possibility  of  these  attacks 
being  due  to  imitation,  or  to  feigning,  or  most  likely  to 
hysteria,  but  finally  decides  they  are  epileptic. 

I  dissent  from  the  view  of  this  writer  that  genuine 
epilepsy  may  become  epidemic  in  schools  and  in  hos- 
pitals. In  my  opinion  the  instances  of  this  kind 
should  unquestionably  be  classed  as  convulsions  due 
to  hysteria. 

I  agree  with  him  that  it  was  possible  for  the  atten- 
dant to  acquire  epilepsy  after  seven  weeks  of  arduous 
labor  in  the  care  of  a  violent  epileptic ;  not,  how- 
ever, so  much  because  his  charge  had  epilepsy,  but 
because  of  the  great  stress,  mental  and  physical,  and 
the  extreme  fatigue  such  labor  imposed  on  him, 
combined  to  some  extent  with  the  possibilities  of 
suggestion  on  an  individual  so  prepared. 

As  to  the  power  of  an  epileptic  attack  to  excite  a 
seizure  in  another  epileptic,  I  do  not  for  a  moment 
doubt,  though  it  is  comparatively  rare,  and  I  believe 
the  constant  association  of  epileptics,  sensitive  at 
first  in  this  way,  with  other  epileptics  who  have  fre- 
quent seizures,  causes  them  in  time  to  lose  such  sen- 
sibility entirely. 

I  have  observed  that  such  instances  in  a  large 
epileptic  community  become  in  time  extremely  infre- 
quent. A  few  days  after  a  large  number  of  epilep- 
tics of  all  types  and  characters  had  been  brought 
together,  about  75  of  them  had  to  eat  in  a  common 
dining-room.  A  violent  seizure  occurred  at  the 
dinner-table  one  day ;  the  table  was  knocked  over,  and 
7 


98  ETIOLOGY. 

great  noise  and  confusion  resulted.  In  a  few  seconds 
four  other  epileptics  were  in  convulsions,  as  the  result 
of  the  first  seizure. 

In  a  few  days  the  occurrence  of  a  single  fit  in  this 
room  no  longer  had  the  power  of  causing  attacks  in 
others  accustomed  to  the  disturbance. 

A  chief  nurse  reported  an  instance  in  which  a  man 
had  a  violent  attack  at  midnight  and  awakened  his 
companions  about  him,  three  of  whom  at  once  had 
epileptic  convulsions;  but  they  were  not  hysterical 
in  any  degree,  the  shock  of  sudden  fright  having 
brought  on  the  attacks. 

I  recall  two  instances  in  which  a  young  woman 
went  into  a  convulsion  at  the  sight  of  a  companion  so 
affected,  both  having  occurred  at  night. 

It  has  also  been  observed  that  when  epileptic  men 
and  women  meet  in  common  assembly  for  religious 
worship,  or  to  see  a  play,  both  sexes  have  more  at- 
tacks proportionately  than  when  one  or  the  other 
attends  alone.  The  reasons  for  this  may  be  found  in 
the  psychic  stimulation  of  the  sexual  passions,  a 
recognized  exiciting  cause  in  some  cases. 

According  to  Masso,  Pinel  always  began  the  exam- 
ination of  a  patient  by  asking  him  whether  he  had 
not  had  some  fright  or  great  vexation.  The  same 
author  states  that  through  the  vivid  impressions 
emotions  may  produce,  the  same  effects  may  be  sus- 
tained, as,  for  instance,  through  a  blow  on  the  head  or 
some  physical  shock.  Fear  causes  the  loss  of  conscious- 
ness, sight,  and  speech. 

Beger  reports  the  cases  of  two  perfectly  healthy  old 
men,  one  sixty-five,  the  other  seventy  years  of  age, 
who  had  epileptic  fits  immediately  after  being  fright- 
ened, though  they  had  never  suffered  in  that  way 
before,  nor  were  they  predisposed  to  such  a  disease. 

Kohts,  in  his  account  of  the  maladies  caused  by 
fright  during  the  seige  of  Strasburg  in  1870,  gives  a 


IMMEDIATE  CAUSES  ACTIVE  IN  EARLIER  YEARS.       99 

minute  description  of  the  cases  of  paralysis  agitans 
and  of  convulsions  which  he  observed;  while  we 
find  numerous  references  in  Hack  Tuke's  "  Dictionary 
of  Psychological  Medicine  "  to  the  emotional  state  as 
a  cause  of  epileptic  attacks,  in  many  of  which  were 
characteristic  convulsions. 

In  Hecker's  admirable  work  on  "  The  Epidemics  of 
the  Middle  Ages,"  mentioned  by  Tuke,  there  is  a  de- 
scription of  the  "dancing  mania"  and  "tarantism"; 
parts  of  which  are  of  interest  in  this  connection. 
"  It  was,"  says  Hecker,  "  a  convulsion  which  infuriated 
the  human  frame  in  the  most  extraordinary  manner 
and  excited  the  astonishment  of  contemporaries  for 
more  than  two  centuries.  As  early  as  1374,  assem- 
blages of  men  and  women  who  had  come  from  Ger- 
many, were  se*en  at  Aix-la-Chapelle,  and,  united  by 
one  common  delusion,  they  exhibited  to  the  public, 
both  in  the  streets  and  in  churches,  the  following 
strange  spectacle :  They  formed  circles,  hand  in  hand, 
and,  appearing  to  have  lost  control  over  all  their 
senses,  continued  dancing  for  hours  in  wild  delirium, 
until  they  fell  to  the  ground  in  exhaustion.  While 
dancing  they  neither  saw  nor  heard,  but  were  haunted 
by  visions,  their  fancies  conjuring  up  spirits  whose 
names  they  shrieked  out.  When  the  disease  was 
completely  developed  the  attack  began  with  epileptic 
convulsions." 

There  is  probably  no  cause  to  doubt  that  these 
frenzied  states  were  at  first  free  from  any  taint  of  real 
epilepsy,  while  there  is  as  little  to  doubt  that  the  long 
continuance  of  such  states  may  lie  at  the  root  of  true 
epileptic  convulsions.  We  need  only  remember  that 
a  single  convulsion,  by  leaving  what  may  be  termed 
a  physical  stain,  definitely  thereafter  perpetuates  its 
kind. 

Prolonged  Anxiety,  Grief,  and  Over-work. — Like 
insanity,  no  list  of  causes  of  epilepsy  would  be  com- 


IOO  ETIOLOGY. 

plete  which  did  not  include  forms  of  mental  stress 
or  disorder,  acute  or  chronic,  due  to  great  anxiety, 
over-work,  or  grief.  It  has  been  my  experience  that 
such  causes,  comparatively  rare  at  best,  exist  in  far 
greater  proportion  in  women  than  in  men,  and  that 
they  are  most  active  about  the  age  of  puberty. 

On  this  point  I  do  not  agree  with  Sir  William  R. 
Gowers,  who  states  that  in  a  series  of  forty-eight  cases 
apparently  due  to  this  cause,  males  predominated, 
and  that  ' '  this  cause  is  effective  late  in  life  more  fre- 
quently than  most  others." 

It  has  also  been  my  experience  that  over-work  and 
great  anxiety  simply  act  as  immediate  or  exciting 
causes  in  cases  that  bear  a  predisposition  to  the  disease, 
this  predisposition  being  effectively  increased  by  the 
epoch  of  puberty. 

Considering  all  these  factors  together,  I  found  them 
to  be  the  cause  of  epilepsy  in  16  out  of  509  women,  and 
6  out  of  814  men,  being  about  3  per  cent,  of  the  former 
and  about  two-thirds  of  1  per  cent,  of  the  latter. 

Several  cases  among  the  women  appeared  in  girls 
at  school,  ranging  in  age  from  twelve  to  sixteen,  the 
"stress  of  ambition"  being  the  exciting  cause  in  some 
of  them ;  the  striving  for  school  honors ;  long  hours  of 
study  in  vitiated  atmospheres;  improper  food;  in- 
attention to  matters  of  health,  and  things  of  like  nature 
common  to  the  age  of  school-girl  life. 

I  recall  particularly  the  case  of  a  girl  of  excellent 
natural  ability,  bright,  quick,  energetic,  and  especially 
devoted  to  music.  She  was  pushed  along  in  her  work 
by  a  no  less  ambitious  but  most  unwise  mother,  with 
the  result  that  at  the  age  of  fourteen  years  the  girl 
developed  epilepsy  in  the  worst  form,  and  at  the  age  of 
eighteen  was  hopelessly  demented.  She  is  still  sub- 
ject to  frequent  convulsions. 


CHAPTER  V. 
ETIOLOGY.— PART  II. 

Trauma.  Proportion  of  Cases  due  to  Trauma.  Gastrointestinal  Dis- 
orders. Lead  Poisoning.  Renal  Disease.  Heart  Disease.  Tobacco. 
Disorders  of  Menstruation.  Pregnancy  and  Maternity.  Masturbation. 
Syphilis.  The  Influence  of  Sleep.  Sporadic  Causes:  Congenital  Brain 
Defects;  Hypertrophy;  Hydrocephalus;  Fatigue. 

TRAUMA. 

The  chief  point  of  interest  in  connection  with  the 
surgical  treatment  of  epilepsy,  which  is  fully  discussed 
in  a  separate  chapter,  is  based  almost  wholly  on  the 
fact  that  injuries  of  certain  kinds  about  the  head  and 
in  connection  with  the  spinal  column,  not  infrequently 
lead  to  epilepsy. 

It  is  also  claimed  that,  in  addition  to  injuries  of  the 
cerebrospinal  nervous  system,  injuries  to  peripheral 
nerves  may  cause  epileptic  phenomena,  and,  while 
I  agree  with  the  possibility  of  this,  such  a  case  has 
not  come  under  my  observation  that  I  recall. 

It  may  be  noticed  that  I  speak  of  "epileptic 
phenomena"  due  to  such  causes  instead  of  epilepsy 
proper,  for  I  do  not  hold  that  such  convulsions  are 
anything  else  than  epileptiform — like  epilepsy — in 
the  beginning. 

It  was  by  irritating  or  cutting  the  sciatic  nerve  that 
Brown-Sequard  succeeded  in  rendering  guinea-pigs 
epileptic. 

Traumatic  lesions  of  the  cranium  and  the  cerebrum 
cause  epilepsy  without  any  predisposition  to  the  dis- 
ease. In  such  cases  there  is  generally  some  physical 
evidence  of  the  injury,  or  a  clear  history  that  such  an 
injury  was  received,  though  there  are  cases  in  which 


102  ETIOLOGY. 

convulsions  follow  simple  concussion  independent  of 
any  actual  physical  lesion  whatever. 

A  child  three  years  old  fell  from  a  veranda  to 
the  ground,  a  distance  of  six  feet,  striking  on  its 
head.  It  remained  unconscious  half  an  hour,  then 
a  general  twitching  of  the  body  occurred,  which 
was  shortly  followed  by  a  severe  general  convulsion, 
and  fifteen  minutes  later  by  a  second  one  much  less 
severe,  after  which  vomiting  set  in  and  consciousness 
was  soon  restored. 

Here  the  convulsions  were  due  to  the  concussion, 
but  had  there  been  intracranial  injury  of  any  kind, 
like  hemorrhage,  permanent  organic  epilepsy  might 
have  resulted. 

Westphal  succeeded,  according  to  Fere,  in  rendering 
guinea-pigs  epileptic  through  concussion  by  striking 
them  repeatedly  on  the  head. 

A  blow  on  the  head  which  fractures  the  skull  or 
causes  intracranial  hemorrhage  may  not  be  followed 
by  convulsions  for  some  hours,  or  for  several  days, 
or  until  a  considerable  local  effusion  has  taken  place ; 
the  irritation  resulting  from  the  effusion  causes  the 
convulsions — a  fact  often  proved  by  the  cessation  of 
the  seizures  on  the  removal  of  the  clot,  an  illustration 
of  which  is  found  in  the  case  of  the  midshipman  at 
Annapolis,  reported  by  Keen.* 

Gunshot  wounds  in  which  the  bullet  lodges  in  the 
brain  and  is  not  removed,  may  cause  convulsions 
likely  to  change  into  epilepsy.  The  writer  recalls 
two  cases  of  this  kind,  in  one  of  which  the  bullet  was 
photographed  in  situ  (by  means  of  the  #-ray),  but  it 
could  not  be  removed,  as  it  was  at  the  base  of  the  brain 
in  an  inoperable  position. 

It  is  a  distinction  of  these  cases  worth  mentioning 
now,  that  the  mental  condition  rarely  deteriorates  until 
the  disease  has  existed  for  years,  and  not  even  then 

*  "The  Philadelphia  Medical  Journal,"  Dec.  13,  1902. 


Plate  7. 


Fig.  1. 


Fig.  4.  Fig.  5.  Fig.  6. 

Figs.  1  to  6  show  the  order  of  progression  of  attacks  in  a  case  in  which 
the  initial  spasm — 519  times  in  succession  in  forty-nine  hours — was  confined 
to  the  first  phalanx  of  the  right  thumb.  Death  from  status  epilepticus 
followed  at  the  end  of  that  time.  Careful  pathologic  examinations  of  the 
right  thumb  arid  hand  centers  in  the  brain  failed  to  show  any  lesion  other 
than  a  condition  of  marked  cell  vacuolation  such  as  would  be  expected 
to  follow  extreme  fatigue.  Exhaustion  paralysis  often  follows  localized 
cortical  "discharges"  in  epilepsy  of  this  kind. 


TRAUMA.  103 

unless  the  original  stamina  of  the  patient  was  poor  and 
the  attacks  frequent  and  severe. 

Roswell  Park*  relates  the  case  of  a  man  who  was 
wounded  during  the  charge  up  San  Juan  Hill,  by  a  bul- 
let which  ploughed  its  way  over  the  skull  and  injured 
the  brain,  so  that  three  years  later  the  man  had  hemi- 
plegia, and  epileptic  seizures  which  appeared  weekly. 

As  a  rule,  the  convulsions  due  to  trauma  are  of  the 
Jacksonian  type,  which  appear  locally  in  one  arm,  or 
leg,  or  on  one  side  of  the  body.  This  is  because  the 
injury  is  local,  affecting,  as  a  rule,  a  limited  portion 
of  the  cortex,  generally  in  or  near  the  motor  region. 

Such  cases,  as  I  have  before  stated,  are  referred 
to  as  organic  epilepsy,  and  even  though  they  begin 
locally,  they  occasionally  show  a  tendency  to  spread 
and  involve  all  parts  of  the  brain,  and  necessarily 
all  parts  of  the  body  as  well. 

We  must  not,  however,  be  led  into  supposing  that 
every  epileptic  seizure  that  begins  locally  is  Jacksonian 
and  due  to  a  fixed  organic  lesion  capable  of  demon- 
stration. 

I  reported  the  case  of  a  woman  f  who  had  519 
well-marked  attacks  in  forty-nine  hours,  the  initial 
manifestation  of  each  attack  being  the  quick,  sharp 
contraction  of  the  first  phalanx  of  the  right  thumb, 
then  the  whole  thumb,  next  the  hand,  the  forearm,  the 
whole  arm,  and  finally  the  right  side  of  the  body. 
She  died  in  status  epilepticus  which  supervened  after 
she  had  had  about  200  attacks.  A  careful  microscopic 
study  of  numerous  sections  of  the  brain  from  the  right 
thumb  center  and  its  vicinity  showed  no  lesion  what- 
ever beyond  a  condition  of  cell-vacuolation,  that  we 
would  naturally  expect  as  the  result  of  extreme  ex- 
haustion.    (See  Plate  7.) 

It  is  of  interest  to  add  that,  while  the  seizures  in  this 

*  "American  Medicine,"  Nov.  22,  1902. 

t  "New  York  Medical  Journal,"  March  13,  1899. 


104  ETIOLOGY. 

case  invariably  began  in  the  right  thumb,  they  quickly 
spread  to  the  entire  right  side  of  the  body,  and  re- 
mained there  as  long  as  the  patient  was  kept  pro- 
foundly under  the  influence  of  chloroform,  which  was 
done  during  nine  of  the  forty-nine  hours  she  was  ill; 
but  when  the  chloroform  was  withdrawn,  they  quickly 
involved  the  entire  left  side  as  well. 

The  same  manner  of  extension  of  the  attack  may 
take  place  in  cases  in  which  there  is  a  definite,  circum- 
scribed, organic  lesion,  and  in  the  surgical  treatment 
of  such  cases  it  is  possible  for  the  operator  to  be  misled 
into  cutting  down  on  a  point  to  which  the  symptoms 
have  radiated,  and  which  does  not  represent  the  true 
seat  of  the  lesion. 

In  the  milder  cases  of  Jacksonian  epilepsy,  as  I 
have  before  pointed  out,  consciousness  is  not  lost,  in 
some  cases  not  even  greatly  impaired,  the  patient 
being  able  to  recall  after  the  attack  what  took  place 
while  it  was  in  progress.  (Vide  case  J.  P.,  described 
under  Jacksonian  Epilepsy,  Chapter  V.) 

Some  writers  claim  that  lesions  of  the  spinal  cord 
may  produce  epilepsy,  and  more  often  epileptiform 
manifestations. 

Brown-Sequard  observed  the  occurrence  of  epilepsy 
after  experimental  lesions  on  the  spinal  cord  of  guinea- 
pigs,  such  as  complete  transverse  sections  of  the  pos- 
terior column,  of  the  posterior  horns,  and  of  the  anterior 
and  lateral  columns,  and  Fere  states  that  in  man  a 
number  of  cases  have  been  observed  in  which  epilepsy 
resulted  from  compression  of  the  cord  by  a  tumor, 
traumatism,  or  some  disease  of  the  vertebrae. 

A  letter-carrier,  thirty-four  years  of  age,  suffering 
from  multiple  sclerosis  of  the  brain  and  spinal  cord, 
developed  well-marked  convulsions  which  appeared 
at  first  once  a  month;  later  they  increased  to  three 
or  four  a  month,  then  occurred  daily.  Suddenly 
they  ceased  for  almost  a  year,  and  during  that  time 


TRAUMA.  105 

his  malady  progressed  rapidly,  the  pathologic  changes 
in  the  cord  having  become  so  far  advanced  as  to 
entirely  destroy  control  of  the  centers  governing  the 
bladder  and  the  rectum. 

The  convulsions  in  this  case  were  thought  at  first 
by  the  attending  physician  to  be  due  to  a  "tumor  in 
the  brain,"  and  the  patient  was  trephined,  though 
necessarily  without  beneficial  results. 

Five  years  after  the  beginning  of  his  illness,  his 
convulsive  attacks  appeared  to  cease  entirely,  while 
the  multiple  sclerosis  grew  steadily  worse. 

In  the  writer's  opinion,  such  cases  should  not  be 
classed  as  genuine  epilepsy,  for  it  is  clear  that  the  con- 
vulsions were  merely  an  incident  of  a  graver  organic 
disorder,  just  as  they  might  have  been  of  some  simpler 
organic  disease  severe  enough  only  to  excite  reflex 
convulsions. 

It  is  interesting  to  note  in  this  connection  the 
functional  division  of  the  cerebro-nervous  system 
into  three  parts  by  Hughlings-Jackson,  if  for  no  other 
purpose  than  that  of  using  such  divisions  as  aids  in 
explaining  the  probable  seat  of  the  lesion  in  epileptic 
seizures  of  different  types.  Jackson  divides  the 
nervous  system  into  three  levels :  Highest,  middle,  and 
lowest;  the  latter  corresponding  practically  with 
Marshall  Hall's  spinal  system  in  including  the  gray 
matter  of  the  spinal  cord  in  its  upward  prolongation 
in  the  brain  as  far  as  the  oculomotor  nucleus. 

The  centers  in  this  "level"  are  sensorimotor  and 
govern  the  fixed  automatic  acts  like  walking,  and  also 
control  the  centers  of  respiration,  deglutition,  defeca- 
tion, and  urination;  and  we  may  say  these  centers 
are  removed  one  degree  from  the  periphery. 

Above  this  spinal  system,  or  lowest  level,  lie  the 
centers  of  the  middle  level,  "functionally  definite,  but 
anatomically  not  so  readily  definable"  as  were  the 
lowest  centers. 


I06  ETIOLOGY. 

This  level,  too,  is  sensorimotor  in  character,  being 
on  the  motor  side  and  practically  synonymous  with 
the  motor  area  outlined  by  Ferrier,  including  the 
corpora  striata.  Sensorily  speaking,  this  middle  level 
includes  probably  the  greater  part  of  the  temporo- 
sphenoidal  lobe,  the  gyrus  fornicatus,  and  the  inferior 
parietal  lobule. 

The  centers  of  the  middle  level  are  far  more  delicate 
and  complicated  and  far  less  automatic  than  those  of 
the  lowest  level,  and  we  may  say  they  stand  two  degrees 
removed  from  the  periphery. 

The  third  and  highest  level  embraces  the  superior 
intellectual  centers  in  the  brain ;  those  that  are  believed 
to  lie  in  the  anterior  or  preparietal  lobe  and  in  the  pos- 
terior or  occipital  region.  These  are  still  less  auto- 
matic than  the  centers  of  the  middle  level,  and  they 
in  turn  are,  so  to  speak,  three  degrees  removed  from  the 
periphery. 

It  is  still  a  mooted  question  as  to  whether  the 
frontal  lobes  are  motor  to  any  extent  or  not.  Hugh- 
lings- Jackson  maintains  they  are,  and  we  are  justified, 
for  the  present  at  least,  in  assuming  all  parts  of  this 
highest  level  to  be  sensorimotor;  the  sensory  functions 
vastly  predominating  in  importance  over  the  motor. 

In  this  level  we  must  undoubtedly  look  for  the 
lesions  that  underlie  the  psychic  or  purely  mental 
forms  of  epilepsy — the  silent  seizures  of  the  mind, 
the  "blanks,"  "absences,"  "darknesses,"  spoken  of 
in  Chapter  I. 

This  general  mapping  of  the  cerebrospinal  nervous 
system  into  three  parts,  where  each  part  represents 
the  basis  from  which  epileptic  convulsions  of  different 
types  spring,  is  of  practical  interest  in  a  diagnostic 
way,  even  though  the  functional  and  anatomical 
relationship  of  the  three  levels  generally  acts  in 
harmony  in  the  closest  alliance  and  as  a  correlated 
whole. 


TRAUMA.  I07 

Still  there  are  numerous  instances,  as  we  shall  see 
later  on,  where  each  acts  independently  of  the  other, 
and  so  it  is  they  afford  a  basis  for  the  explanation  of 
certain  circumscribed  fits.  In  this  connection  I  will 
only  add  that  convulsions  due  to  spinal  cord  diseases, 
pure  and  simple,  may,  not  infrequently,  fail  to  reach 
up  into  true  epilepsy  at  all,  because  the  sudden  exces- 
sive discharge  or  explosion  of  nervous  force  in  such 
comparatively  low  centers  as  those  in  the  cord  fails 
to  seriously  involve  any  part  of  the  brain. 

PROPORTION  OF  CASES  DUE  TO  TRAUMA. 

Trauma  is  more  frequently  the  cause  of  epilepsy 
in  men  than  in  women.  In  509  women  who  came  under 
my  observation,  it  was  the  cause  in  18  only,  or  about 
3 J  per  cent. ;  while  in  814  men  it  was  the  cause  in  70, 
or  about  8^-  per  cent.,  being  nearly  three  times  greater 
in  men  than  in  women. 

In  73  cases  out  of  88  occurring  in  both  sexes,  the 
injury  was  received  before  the  twentieth  year,  again 
showing  it  to  be  the  young  who  suffer  most,  other  age 
periods  being  as  follows:  Boys  under  ten  years,  31 
cases;  from  ten  to  twenty  years,  25  cases;  over 
twenty  years,  14  cases.  Girls  under  ten  years,  11 
cases;  ten  to  twenty  years,  6;  over  twenty  years,  1 
only. 

Among  the  ways  in  which  injuries  that  lead  to 
epilepsy  are  received,  may  be  mentioned  the  follow- 
ing from  personal  observation:  "Kicked  on  the  head 
by  a  horse,"  "fell  on  the  ice  while  skating,"  "struck 
on  the  head  by  a  falling  limb,"  "fell  from  a  scaffold," 
etc. ;  while  the  greater  number  are  simply  ascribed 
to  an  "injury  to  the  head,"  most  of  these  being 
received  by  the  young,  whose  fear  of  the  liability  to 
injury  is  over-balanced  by  a  lack  of  judgment  and  a 
healthy  excess  of  animal  life  that  leads  them  into 
perilous  positions. 


108  ETIOLOGY. 

In  other  rare  cases  epilepsy  may  directly  follow 
injury  to  the  spine. 

When  C.  M.  H.  was  eight  years  old,  he  was  hurt  by 
a  man  kicking  him  "over  the  lower  end  of  the  spine." 
From  that  time  until  he  was  eleven  he  had  spells  of 
"losing  himself,"  which  came  on  from  three  to  four 
times  a  day.  Then  he  began  to  have  grand  mal 
seizures  which  were  announced  some  time  before  they 
appeared  by  a  "  general  chilly  sensation." 

The  following  is  illustrative  of  the  worst  form  of 
epilepsy  due  to  trauma: 

W.  H.  J.  first  came  under  my  care  in  1896,  when  he 
was  twenty-three  years  of  age,  having  been  an  epileptic 
five  years.  His  family  history  was  good.  As  a  boy 
he  worked  on  a  farm;  he  was  never  dissipated  and 
never  ill  until  his  epilepsy  began  in  his  eighteenth 
year. 

In  passing  along  the  road  during  a  wind  storm,  he 
was  struck  on  the  right  side  of  the  head  just  above 
the  ear  by  a  falling  limb.  He  remained  unconscious 
for  some  hours ;  there  was  a  little  fever,  and  he  stayed 
in  bed  for  several  days. 

The  attending  physician  could  not  find  any  evidence 
of  fracture  of  the  skull,  nor  were  there  any  symptoms 
of  paralysis  or  of  any  disturbance  of  the  brain  until 
he  developed  convulsions  "  a  few  weeks  later."  These 
were  considered  the  result  of  the  blow  on  the  head, 
though  for  some  reason  an  operation  was  not  under- 
taken. 

The  convulsions  were  all  of  the  grand  mal  type  and 
most  severe.  There  was  no  definite  record  of  the  fre- 
quency of  their  occurrence  until  he  was  admitted  to 
the  Craig  Colony  five  years  after  the  receipt  of  the 
injury,  at  which  time  they  occurred  on  an  average 
of  one  every  two  weeks,  being  both  nocturnal  and 
diurnal. 

During  the  inter-paroxysmal  periods  he  was  fairly 
intelligent,  though  his  mental  processes  were  painfully 
slow  and  at  times  extremely  difficult.  He  soon  began 
to  have  "periods  of  marked  somnolence  and  stupor" 
that  came  on  at  times  wholly  independent  of  any 


TRAUMA.  109 

visible  seizure,  though  it  cannot  be  said  that  he  did 
not  have  psychic  seizures  before  them  which  escaped 
notice,  while  at  other  times,  such  periods  followed 
single  attacks  or  a  series  of  them,  the  exhaustion 
which  followed  the  latter  being  most  profound. 

When  passing  through  the  worst  of  these  periods, 
he  was  incapable  of  being  aroused;  the  plantar  and 
corneal  reflexes  were  abolished,  the  pulse-beat  full 
and  slow,  and  respiration  was  stertorous  and  labored. 

Trephining  was  considered,  but  was  abandoned 
because  of  the  length  of  time  that  had  passed  since 
the  receipt  of  the  injury,  and  because  of  the  generally 
unsatisfactory  condition  of  the  patient. 

He  was  given  the  bromids  in  small  doses,  thinking 
they  might  check  the  seizures,  but  they  "  depressed 
him  mentally  and  physically"  to  such  a  degree  that 
they  had  to  be  withdrawn,  while  they  wholly  failed 
at  any  time  to  lessen  the  convulsions  either  in  fre- 
quency or  severity. 

At  one  time  he  averaged  three  seizures  a  week  for 
six  months,  while  at  another  time  he  went  six  months 
without  any  at  all.  The  attacks  of  stupor  increased 
in  frequency  during  the  last  two  years  and  he  passed 
ultimately  into  status  epilepticus  as  the  result  of  a 
long  series  of  attacks.  His  temperature  went  up  to 
1040  F.,  and  death  followed  from  exhaustion. 

The  autopsy  showed  no  evidence  of  a  former  frac- 
ture, though  the  skull-cap  was  much  thickened 
anteriorly.  The  dura  was  adherent  at  the  site  of 
the  Pacchionian  bodies  on  the  sides,  causing  laceration 
of  the  brain  and  its  covering  when  it  was  removed. 
A  marked  atrophy  of  the  central  portion  of  the  right 
temporosphenoidal  lobe  was  present,  as  well  as  atrophy 
of  the  right  posterior  parietal  lobe  involving  the  motor 
region.  The  pia  was  firmly  adherent  to  the  brain 
over  the  atrophied  region.  Small  cysts  were  found 
in  the  choroid  in  the  lateral  ventricles,  the  cyst  on  the 
right  side  being  the  larger. 

The  convulsions  in  this  case  were  clearly  due  to  the 
results  of  the  injury,  these  results  being  in  the  form  of 
a  subdural  hemorrhage  that  compressed  the  brain  in 
such  a  manner  as  to  interfere  with  its  nutrition,  with 


IIO  ETIOLOGY. 

consequent  atrophy,  the  adhesions  being  the  result  of 
the  local  inflammatory  changes  caused  by  the  blow. 

GASTROINTESTINAL  DISORDERS. 

The  epilepsies  due  to  derangements  of  this  part  of 
the  nutritional  system  are,  in  my  opinion,  of  greater 
importance  than  they  are  generally  supposed  to  be. 

It  is  less  difficult  now  to  give  such  derangements  a 
reasonable  clinical  value  than  it  is  to  elaborate  the 
method  of  their  action  in  the  laboratory  or  otherwise. 
However,  if  the  former  is  true,  the  latter  in  time  must 
surely  follow,  and  we  have  full  confidence  that  the 
chemical  pathology  of  the  future  is  destined  to  play 
a  role  of  great  importance  in  isolating  the  cause  of 
the  disease  in  some  cases  in  which  it  is  yet  obscure 
as  a  laboratory  problem,  and  as  yet  not  fully  proved 
in  a  clinical  way;  only  based  on  clinical  evidence 
that  seems  fairly  conclusive  and  certainly  of  much 
practical  importance. 

By  gastrointestinal  disorders  I  do  not  mean  so 
much  to  include  diseases  of  the  alimentary  tract,  like 
chronic  diarrhea  and  ulcers  of  the  stomach,  as  I  do 
acute  indigestion  and  intestinal  toxemias. 

Irrespective  of  the  absorption  of  poisonous  matter 
into  the  blood  from  the  alimentary  canal,  the  irrita- 
tion of  the  peripheral  nerves  (visceral)  in  this  locality 
may  alone  cause  reflex  convulsive  phenomena  that 
may  persist  as  epilepsy;  and  it  is  a  notable  fact  that 
the  irritation  of  such  nerves  seldom  causes  sensations 
which  reach  consciousness,  while  any  irritation  of  the 
cerebrospinal  nerves  is  at  once  realized  through  the 
pain  induced. 

Beginning  with  the  buccal  cavity,  we  find  that 
dental  caries  has  been  ascribed  as  a  cause  of  the 
disease  in  some  cases,  though  we  incline  to  doubt  that 
this  alone  is  ever  capable  of  producing  it.  It  is  far 
more  probable  that  the  caries  is  associated  with  some 


GASTROINTESTINAL    DISORDERS.  Ill 

disturbance  of  the  alimentary  tract  which  is  the  actual 
cause,  though  we  should  never  fail  to'  carefully  ex- 
amine the  mouth  and  teeth  of  every  epileptic  and  cor- 
rect all  possible  sources  of  irritation  in  either,  remem- 
bering that  the  important  process  of  nutrition  begins 
here,  and  that  the  best  digestion  is  imperatively  de- 
manded by  the  epileptic. 

In  many  cases  in  which  difficult  dentition  is  sup- 
posed to  be  the  exciting  cause  of  epileptic  phenomena, 
it  is  always  worth  our  while  to  look  carefully  for  evi- 
dence of  gastric  or  intestinal  derangement. 

In  speaking  previously  of  the  effects  of  difficult 
dentition,  it  was  noted  that  indigestion  or  stomach 
trouble  was  often  coupled  with  it,  and  I  do  not  doubt 
that  in  some  of  these  cases  they  constitute  the  sole 
cause,  the  eruption  of  the  teeth  having  nothing  to  do 
with  it. 

A  rather  broad  inference  of  a  practical  character 
may  be  made  in  this  connection  to  show  the  manner 
in  which  the  products  of  intestinal  indigestion  cause 
convulsive  phenomena,  and  later  on  true  epilepsy. 

I  have  previously  referred  to  ' '  the  storing  of  nervous 
force  or  energy  and  the  manner  of  its  discharge." 
"If,"  as  Gowers  says,  "we  can  perceive  the  conditions 
that  underlie  normal  nervous  action  in  the  nerve 
centers,  the  phenomena  of  epilepsy  will  become  in 
some  degree  less  mysterious.  In  health,  energy  is 
liberated  in  instant  response  to  a  definite  stimulation. 
Such  capacity  for  instant  action  involves  a  delicate 
equipoise  of  the  processes  for  the  liberation  of  nerve 
force  and  for  its  restraint  and  control.  The  balance 
must  depend  on  the  processes  of  nutrition  in  ike  nerve 
structures,  for  the  liberation  of  energy  depends  on  the 
occurrence  of  chemical  processes  under  the  influences 
of  life — processes  which  must  ever  be  on  the  verge 
of  destruction. ' ' 

Properly  nourished  and  under  proper  inhibitory  con- 


112  ETIOLOGY. 

trol,  sensory  and  motor  nerve  cells  remain,  so  to  speak, 
in  statu  quo,  awaiting  the  stimulus  that  will  cause  them 
to  give  off  their  energy  in  a  normal  way.  In  such  cells 
the  equilibrium  is  justly  maintained.  In  the  epileptic 
state  this  equilibrium  is  temporarily  impaired  or 
destroyed.  The  cell  may  be  undersized,  or  poorly 
insulated,  and  incapable  in  the  first  place  of  storing 
a  normal  amount  or  degree  of  energy,  and  in  the  second 
place  of  retaining  it  after  it  is  stored — holding  it,  we 
may  say,  against  calls  abnormal  in  kind. 

There  is  undue  readiness  of  the  cells  to  act,  to  re- 
spond to  vagrant  and  unphysiologic  forms  of  stimu- 
lation, and  so  it  is  that  dissipated,  purposeless  move- 
ments, convulsions,  or  even  a  series  of  them,  is  the 
result. 

Now  note  the  one  factor  that  seems  to  be  capa- 
ble above  all  others  of  disturbing  this  marvelous 
balance,  that  wonderful  state  of  cell-equilibrium, 
namely,  the  little-understood  processes  of  nutrition, 
whether  in  health  or  disease. 

Nutrition  can  be  disturbed  in  other  ways  than  merely 
through  the  media  that  carry  pabulum  to  the  cell,  for 
we  have  seen  how  emotional  shock  may  so  affect  the 
function  of  nerve  tissues  as  to  disarrange  its  balance, 
causing  at  first  irregular  nerve  discharges,  and  later 
on,  epilepsy;  but  it  is  the  character  of  the  material 
carried  to  the  cell  for  the  purpose  of  its  constant  recon- 
struction that  has  most  to  do  with  its  type  of  action. 

If  the  stomach  and  intestinal  canal  do  their  parts 
in  a  healthy,  natural  way;  if  they  digest,  absorb,  and 
create  only  the  pabulum  the  body  needs  for  its  healthy 
preservation,  there  need  be  no  convulsions  due  to 
faults  in  the  action  of  this  part  of  the  human  economy ; 
but  the  stomach  and  intestinal  canal  are  palpably 
at  fault  at  times,  for  they  manufacture  a  variety  of 
more  or  less  harmful  substances,  some  of  them  dis- 
tinctly poisonous. 


GASTROINTESTINAL    DISORDERS.  II3 

According  to  Bouchard,*  the  apparently  most  inno- 
cent foods,  including  the  flesh  of  muscle,  are  toxic  at 
times,  because  of  the  mineral  matter,  chiefly  potash, 
they  contain. 

Bile,  through  its  coloring  matters,  may  also  become 
poisonous.  It  is  claimed  that  the  poison  in  an  extract 
of  2.5  grammes  of  putrified  meat  is  sufficient  to  kill. 
The  toxic  effects  of  constipation  are  varied  and  well 
known,  being  due  chiefly  to  potash  and  ammonium, 
and  the  combination  of  organic  principles  which  in- 
cludes alkaloid  substances. 

The  chief  subjective  symptoms  of  putrefactive 
changes  going  on  in  the  intestinal  canal  consist  of 
fatigue,  depression,  headache,  buzzing  in  the  ears, 
visual  disturbances,  vertigo,  and  irritability  of  temper 
which  may  often  be  marked. 

Bouchard  speaks  of  the  possibility  of  convulsions 
in  cases  of  dyspepsia  in  which  there  is  urea  of  sufficient 
degree  to  cause  nausea  and  vomiting,  and  this,  too, 
without  any  disease  of  the  kidneys,  only  an  incapacity 
on  their  part  to  help  eliminate  the  products  of  fer- 
mentative putrefaction  going  on  in  the  alimentary 
canal.  According  to  modern  chemical  pathology, 
there  is  scarcely  an  adjunct  to  the  entire  nutritional 
system,  including  all  its  anatomical  divisions,  and  their 
several  secretions,  that  does  not  suffer  serious  functional 
impairment  or  disease,  capable  of  hindering  or  de- 
stroying nutrition,  and  we  should  seek  to  ascertain 
the  possible  existence  of  any  of  these  in  every  case  that 
comes  under  our  care.f 

Finally,  individual  susceptibility  to  certain  foods, 
harmless  in  most  persons  but  poisonous  in  others, 
should  not  be  overlooked;    such  foods  usually  consist 

*  "Auto-intoxication  in  Disease,"  1895. 

f  The  author  commends  most  highly  the  reading  in  this  connection  of 
Herter's  book  on  "Chemical  Pathology,"  especially  the  chapter  on  the 
Chemical  Pathology  of  Intestinal  Indigestion. 


114  ETIOLOGY. 

of  shellfish  and  certain  fruits,  including  peaches  and 
strawberries. 

MISCELLANEOUS  CAUSES. 

Lead  Poisoning. — Most  authorities  agree  that  epil- 
epsy may  occasionally  be  due  to  chronic  poisoning 
from  lead,  constituting  saturnine  epilepsy,  though  I 
believe  such  a  cause  is  extremely  rare,  for  in  a  total 
of  nearly  1600  cases  it  was  the  cause  in  one  only. 

A  boy  of  four  years  scraped  a  quantity  of  fresh  paint 
from  the  side  of  a  house  and  ate  it,  developing  shortly 
afterward  violent  convulsions  which  lasted,  in  a  dimin- 
ishing way,  for  several  days,  when  they  ceased  alto- 
gether. He  then  remained  free  from  them  until  the 
age  of  fourteen,  when  the  stress  of  puberty,  combined 
with  the  effects  of  masturbation ,  caused  them  to  recur 
and  become  permanently  established. 

According  to  Fere,  who  mentions  Tanquel  des 
Planches,  Leuret,  Grisolle,  and  others  in  this  con- 
nection, plumbism  forms  a  favorable  field  for  the 
development  of  epileptic  manifestations,  intoxication 
from  it  producing  acute  epilepsy  which  may  run  into 
serial  attacks  that  end  in  status  epilepticus  or  in 
delirium. 

I  do  not  doubt  the  power  of  this  agency  to  excite 
toxic  convulsive  phenomena,  though  the  comparative 
rarity  of  such  intoxication  makes  epilepsy  from  it 
infrequent. 

Tobacco. — In  six  cases  that  I  have  seen,  all  being 
boys  under  sixteen  years  of  age,  cigarette  smoking  was 
believed  to  be  the  exciting  cause  of  the  disease.  It 
is  worth  noting,  however,  that  it  appeared  in  all  of 
them  about  the  age  of  puberty,  and  mostly  in  boys 
whose  ancestry  was  not  good,  which  two  important 
facts,  .together  with  the  tendency  to  masturbation  at 
this  age,  should  cause  us  to  be  careful  in  ascribing 
the  cause  to  cigarette  smoking  alone. 


MISCELLANEOUS    CAUSES.  115 

I  do  not  doubt  the  power  of  intense  poisoning  from 
nicotin  to  undermine  the  stamina  in  selected  cases  in 
a  way  to  make  the  individual  more  susceptible  to 
disease,  among  these  being  epilepsy  and  insanity. 

An  adult  male  epileptic  declared  that  the  chewing  of 
tobacco  always  made  him  worse,  and  resolved  time  and 
again  to  discontinue  the  practice,  but  could  not  do  so. 

Besides  the  possible  poisonous  effects  of  the  tobacco 
in  such  a  case,  the  gastric  disturbance,  the  toxemia, 
induced  by  it  may  have  had  something  to  do  with 
bringing  on  the  convulsions. 

Gowers  speaks  of  a  boy  whose  epilepsy  came  on  as 
the  apparent  result  of  frequent  nausea  caused  by 
working  in  a  tobacco  factory. 

A  woman  of  twenty-eight,  whose  ancestry  was  bad — 
epilepsy,  alcoholism,  and  tuberculosis  being  in  the 
family,  in  whom  the  disease  came  on  at  seventeen 
years,  after  scarlet  fever — claimed  for  a  long  time  that 
she  never  had  a  convulsion  when  she  smoked,  though 
the  observations  of  her  physician  did  not  bear  this 
out.  Her  fondness  for  the  habit  probably  caused 
her  to  make  this  statement  because  she  did  not  wrant 
to  give  it  up. 

Renal  Disease. — We  have  previously  referred  to 
scarlatinal  nephritis  as  a  cause  of  epilepsy,  noting 
its  presence  in  3  per  cent,  or  more  of  all  cases,  and  the 
forms  of  renal  diseases  referred  to  here  more  par- 
ticularly include  the  varieties  of  Blight's  disease. 

The  neurologist  does  not  come  into  contact  with  the 
convulsive  disorders  due  to  uremic  poisoning  as  often 
as  the  general  practitioner,  and  the  latter  is  not  in- 
clined to  treat  such  phenomena  as  epileptic. 

The  influence  of  the  kidney  when  diseased  in  pro- 
ducing morbid  mental  states  has  long  been  recognized ; 
much  valuable  scientific  work  in  this  connection  having 
been  done  by  Prout  and  others,  while  the  subject  has 
been  very  carefully  studied  clinically. 


Il6  ETIOLOGY. 

On  the  other  hand,  the  convulsive  phenomena  due 
to  kidney  lesions  have  also  long  been  recognized, 
though  not  systematically  studied. 

Convulsive  attacks  in  uremic  poisoning  may  develop 
with  a  warning  or  be  preceded  by  such  symptoms  as 
pain  in  the  head,  restlessness,  and  malaise;  and, 
according  to  Osier,*  such  convulsions  may  be  general 
and  identical  in  character  with  those  of  genuine 
epilepsy,  minus  the  epileptic  cry. 

They  may  occur  in  rapid  succession,  the  patient 
being  unconscious  during  the  inter-paroxysmal  period. 
Usually  the  temperature  is  below  normal,  though  it 
may  occasionally  be  above. 

Jacksonian  epilepsy  may  occur  in  uremia,  while 
uremic  amaurosis  (blindness)  may  appear  and  persist 
several  days.     Hearing  may  also  be  temporarily  lost. 

When  the  convulsions  of  uremia  are  followed  by 
hemiplegia,  or  monoplegia,  established  organic  epilepsy 
may  be  the  result.  The  apparent  rarity  of  epilepsy 
due  to  the  results  of  grave  kidney  diseases  in  old 
persons  is  due  to  the  great  fatality  of  the  affection,  the 
patient  generally  succumbing  before  epilepsy  has  be- 
come fully  established  as  an  independent  affection. 

Disorders  of  Menstruation. — These  may  be  either 
functional  or  organic,  and  almost  any  pathologic  cause 
that  deals  with  the  period  of  life,  in  man  or  woman, 
covered  by  the  epoch  of  puberty,  from  the  twelfth  to 
the  sixteenth  or  seventeenth  year,  is  capable  of  mis- 
interpretation, for  the  diseases  that  come  to  light 
at  this  period  are  so  numerous  that  it  is  not  difficult 
to  lay  more  importance  on  one  supposed  causative 
factor  than  that  factor  deserves. 

Substantially  all  authorities  agree  that  irregularities 
in  the  menstrual  function  may  produce  a  long  line  of v 
neurotic  manifestations,  prominent  among  them  being 
epilepsy. 

*  "Practice  of  Medicine,"   1895. 


MISCELLANEOUS    CAUSES.  Iiy 

It  has  long  been  a  semi-medical  tradition,  and 
indeed  it  is  still  in  some  localities,  that  the  establish- 
ment of  the  menstrual  flow  is  apt  to  cure  or  favorably 
influence  ills  of  a  nervous  order  suffered  for  years  up 
to  that  time;  but  there  is  an  abundance  of  clinical 
observation  now  to  show  that  in  the  great  majority 
of  cases  the  opposite  is  more  likely  to  be  the  result, 
especially  in  epilepsy. 

Yoisin,  Fere,  and  Gowers  agree  that  the  menstrual 
function  coincides  with  an  exacerbation  of  the  fits 
in  this  disease,  and  progresses  thenceforth  in  a 
markedly  periodic  form.  This  is  true  to  a  large  extent 
in  many  cases.  I  have  witnessed  it  in  a  score  or  more 
in  the  hundreds  of  epileptic  women  who  have  come 
under  my  care. 

Voisin  goes  so  far  as  to  say  that  menstruation  is 
"the  signal  of  explosion  of  epileptic  attacks.  In 
our  service  I  find  a  quarter  of  the  patients  at  least  in 
whom  menstruation  has  this  influence." 

Once  established,  the  attacks  may  become 
aggravated  by  the  onset  of  dysmenorrhea  or  sup- 
pression of  the  menses.  Women  who  have  epilepsy 
from  such  causes  will  in  most  cases  be  found  to  possess 
a  neurotic  stamina,  though  some  may  become  epileptic 
solely  through  the  stress  of  irregularities  of  the  repro- 
ductive organs,  and  it  is  often  a  matter  of  importance 
to  determine  how  far  functional  disturbances  are 
responsible  and  how  far  they  are  organic. 

Somers  treated  a  patient  by  perforation  in  a  case 
of  epilepsy  in  which  the  cause  was  an  imperforate 
hymen  that  prevented  the  evacuation  of  the  flow, 
after  which  the  convulsions  ceased.  Such  a  cause  is 
not  uncommon,  many  cases  of  the  kind  doubtless 
occurring,  that  are  not  reported.  The  retained  flow 
becomes  septic,  and  poisons  the  nervous  system  by 
absorption. 

A    somewhat    similar    case    (elsewhere    mentioned) 


Il8  ETIOLOGY. 

came  tinder  my  own  observation.  A  married  woman, 
thirty-seven  years  old,  had  an  impervious  uterus  and 
had  never  menstruated.  The  organ  was  substantially 
a  cyst,  and  vicarious  menstruation  appeared  each 
month  in  the  groin. 

The  convulsions  that  developed  at  puberty  had 
persisted  ever  since,  and  became  especially  prominent 
about  the  time  of  the  monthly  flow. 

For  several  reasons  it  was  deemed  best  to  remove 
the  uterus  with  all  its  appendages,  after  which  the  at- 
tacks ceased  entirely,  and  three  years  later  they  had 
not  returned. 

The  Menopause. — The  menopause  is  a  very  infre- 
quent cause  of  epilepsy,  or  even  of  reflex  epileptic 
phenomena.  Up  to  this  time,  I  have  seen  but  two 
cases  due  to  stress  incident  to  the  termination  of 
menstrual  life.  The  reasons  for  this  are  twofold,  as 
follows:  i.  Epilepsy  is  essentially  a  disease  of  early 
life.  2.  A  woman  who  has  successfully  run  the 
gauntlet  of  the  epochs  of  dentition,  of  puberty,  and 
maternity  need  have  little  to  fear  from  that  of  the 
menopause  when  it  follows  anything  like  a  normal 
course  in  its  establishment. 

Pregnancy  and  Maternity. — It  is  far  more  common 
to  see  epilepsy  arise  during  pregnancy,  or  immediately 
after  delivery,  than  at  the  menopause.  Gowers 
speaks  of  ten  cases  in  which  the  first  fit  occurred 
without  obvious  cause  during  pregnane)',  and  of  five 
in  which  it  occurred  after  parturition.  Three  cases 
which  occurred  as  the  result  of  maternity  have  come 
under  the  writer's  observation. 

As  a  rule,  such  cases  at  first  are  described  as  eclamp- 
tic, and  the  great  majority  of  them  are  checked  before 
they  pass  into  epilepsy;  while  others  soon  acquire  all 
the  essentials  of  the  true  disease.  Many  of  them  under 
modern  medical  and  surgical  procedures  are  prevent- 
able,   and   we   mention   some   instances   to   show   the 


MISCELLANEOUS    CAUSES.  119 

disastrous   effects   that  may   follow  failure   to   apply- 
early  and  correct  treatment : 

L.  M.  came  under  my  care  when  she  was  thirty- 
nine  years  old,  having  had  epilepsy  since  she  was 
twenty-three,  when  the  first  convulsion  appeared 
soon  after  the  birth  of  her  child.  She  never  had  a 
convulsion  prior  to  that  time.  During  the  first  five 
years  the  attacks,  very  frequent  at  first,  gradually 
grew  less  so,  but  more  severe  in  kind,  alternating 
between  grand  mat,  petit  mat,  and  psychic.  Gyneco- 
logical examination  showed  a  much  inflamed  cervix 
uteri  and  marked  vaginal  cystocele,  both  doubtless 
of  very  long  standing. 

The  patient's  mental  condition  was  markedly 
impaired,  epileptic  dementia  being  well  established, 
while  the  attacks  still  occurred  from  four  to  five  times 
a  month. 

It  cannot  be  reasonably  doubted  that  epilepsy  in 
this  case  was  due  to  some  injury  suffered  at  the  time 
of  parturition,  the  prompt  repair  of  which  might  have 
saved  the  woman  from  epilepsy  and  insanity  in  the 
end. 

M.  McC.  had  the  first  convulsion  at  thirty-three 
years,  immediately  after  childbirth,  and  when  we  saw 
her  at  the  age  of  thirty-seven,  she  was  a  confirmed 
epileptic,  having  several  attacks  each  month,  all  of 
the  grand  mat  type.  Her  mental  faculties  were 
largely  destroyed,  and  she  was  subject  to  maniacal 
outbursts  of  great  violence,  having  at  such  times 
numerous  unsystematized  delusions  and  hallucina- 
tions. She  finally  became  continuously  insane  and  a 
subject  for  commitment  to  a  hospital  for  that  class. 

M.  H.,  a  married  woman  of  twenty-nine  when  I 
first  saw  her,  developed  epilepsy  at  the  age  of  twenty- 
one,  when  she  had  a  miscarriage,  this  being  her  second 
pregnancy;  the  first  had  required  instrumental  de- 
livery, harmless  alike  to  mother  and  child. 

The  miscarriage  was  induced  at  the  sixth  month 
because  it  was  deemed  necessary  to  save  the  woman's 
life  which  was  threatened  by  the  frequency  and  vio- 
lence of  the  eclamptic  attacks.  Shortly  after  these 
had  subsided,  she  had  slight  psychic  seizures  that 
persisted    occasionally    for    about    four    years,    when 


120  ETIOLOGY. 

grand  mal  attacks  began  to  appear.  After  the  lighter 
attacks  she  was  frequently  automatic,  going  about 
in  a  dazed,  subconscious  state,  doing  a  number  of 
little  things  that  she  had  no  knowledge  of,  and  it  was 
not  long  before  evidences  of  epileptic  dementia  ap- 
peared, which  was  soon  fully  established.  Prevention 
in  this  case,  or  the  possibility  of  early  cure,  was  not 
to  be  so  much  expected. 

Grandin  and  Jarman*  state  that  eclampsia  occurs 
once  in  from  five  to  six  hundred  pregnancies,  unless 
the  woman  develops  an  acute  nephritis  during  preg- 
nancy, when  the  proportion  arises  to  about  25  per 
cent.  In  this  latter  class  of  cases  the  maternal  mor- 
tality averages  about  30  per  cent. 

As  many  as  from  seventy-five  to  one  hundred 
eclamptic  attacks  may  occur  in  twenty-four  hours, 
and  whatever  else  the  prime  etiologic  factor  in  such 
cases,  a  secondary  factor  is  uremia,  this  being  assured 
through  good  results  attained  in  eliminating  the  full 
amount  of  urine. 

Hirst  ("Textbook  on  Obstetrics,"  1899),  in  review- 
ing the  nervous  complications  of  pregnancy,  says: 
"Epilepsy  is  a  rare  complication  of  pregnancy  and, 
as  a  rule,  does  not  influence  unfavorably  the  course 
of  gestation.  The  convulsions  are  often  absent  during 
pregnancy,  but  make  their  appearance  again  during 
and  after  the  puerperium,  or  upon  the  reappearance 
of  menstruation  after  the  child  is  weaned." 

Among  the  causes  of  epilepsy  at  this  period  we 
must  not  overlook  phlegmasia  alba  dolens,  or  milk 
leg.  The  clot  in  such  cases  may  be  carried  to  the 
brain,  one  instance  of  the  kind  being  known  to  the 
writer,  or  the  general  septicemic  state  may  directly 
poison  the  cerebrum,  or  the  local  inflammation  itself 
may  cause  reflex  convulsions. 

Epilepsy  due  to  pregnancy  or  maternity  is  apt  to 

*  "Pregnancy,  Labor,  and  other  Puerperal  States,"  1896. 


MISCELLANEOUS    CAUSES.  121 

assume  the  gravest  aspect,  and  when  eclamptic  at- 
tacks appear  they  ought  to  be  vigorously  treated 
with  a  view  to  preventing  as  soon  as  possible  the 
habituation  of  the  epileptic  impulse. 

Masturbation. — It  is  exceedingly  difficult  to  arrive 
at  any  satisfactory  estimate  as  to  the  number  of  cases 
of  epilepsy  due  to  this  cause.  The  habit  is  common 
among  epileptic  boys,  and  it  is  often  impossible  to  say 
whether  it  was  acquired  before  the  epilepsy  or  after. 

Gowers  contends  that  it  can  be  established  as  a 
cause  only  in  cases  in  which  circumcision  checks  the 
convulsions,  and  that  true  epilepsy  is  seldom  caused 
by  it,  though  it  may  be  a  frequent  cause  of  severe 
habit  spasms  in  boyhood.  It  seems  to  me  that  this 
aims  to  make  a  distinction  without  a  difference. 

Habit  spasms  in  such  individuals,  at  this  age,  and 
due  to  this  cause,  which  are  general  in  character, 
mean,  in  my  opinion,  nothing  more  or  less  than  habit 
epilepsy. 

I  have  personal  knowledge  of  nine  cases  in  boys 
ranging  in  age  from  twelve  to  seventeen  years,  in 
which  the  epilepsy  was  due  to  this  pernicious  practice, 
while  it  was  the  cause  in  the  case  of  one  girl. 

Dana  says  that  masturbation  is  an  occasional  cause 
of  epilepsy;  Holt  classes  it  among  the  reflex  causes 
of  the  disease ;  Lauret  put  it  down  as  the  determining 
cause  in  12  out  of  66  cases  that  he  studied;  while 
Nothnagel  refers  to  it  in  this  way :  ' '  Hereditary  epi- 
lepsy is  generally  esteemed  incurable,  yet  Herpin  and 
Reynolds,  for  example,  have  seen  marked  exceptions 
to  this  rule.  The  same  holds,  according  to  the  latter 
observer,  for  the  disease  when  due  to  masturbation." 

Voisin  writes  at  some  length  on  the  abuse  of  coitus 
as  a  determining  cause  of  epilepsy,  adding:  "Mas- 
turbation plays  the  same  role  in  the  production  of 
epilepsy  as  abuses  in  coitus." 

Syphilis. — Infection  due  to  the  poison   of  syphilis 


122  ETIOLOGY. 

seldom  causes  epileptic  manifestations  that  rise  to  the 
true  form  of  the  disease,  unless  the  brain  or  its  men- 
inges are  involved,  and  even  then  the  convulsive 
attacks  are  more  apt  to  simulate  Jacksonian  epilepsy, 
involving  one  leg  or  arm,  or  a  part  of  the  body  only. 

A  large  number  of  such  cases  have  come  under  my 
care.  The  "spinal  epilepsy"  described  by  Brown- 
Sequard  as  mentioned  by  Gowers,*  and  which  has  a 
superficial  resemblance  only  to  true  epilepsy,  may 
possibly  be  due  to  syphilitic  involvement  of  the  spinal 
cord,  though  more  often  to  other  degenerative  pro- 
cesses. 

Every  practitioner's  personal  experience  affords 
abundant  confirmation  of  the  fact  that  brain  syphilis 
causes  a  type  of  convulsions  which  not  infrequently 
runs  into  genuine  epilepsy. 

The  character  and  course  of  this  type  of  the  disease 
are  quite  distinctive,  closely  resembling  the  epilepti- 
form convulsions  of  paresis  in  many  cases.  Physi- 
ologic and  pathologic  researches  during  the  past 
quarter  of  the  century  have  shown  that  definite  lesions 
of  definite  portions  of  the  brain  give  rise  to  certain 
fixed  symptoms.  We  know  that  the  motor  tracks 
take  their  origin  from  the  central  convolutions,  and 
as  these  tracks  become  smaller  they  pass  through  the 
corona  radiata,  the  internal  capsule,  and  the  cerebral 
peduncle  and  pons  to  the  crossing  of  the  pyramids. 

It  is  clear,  therefore,  that  a  small  lesion  at  the  cortex 
will  produce  a  circumscribed  paralysis  of  a  paretic  con- 
dition, while  a  lesion  of  similar  size  in  the  internal 
capsule,  where  the  fibers  coming  from  the  cortex  are 
crowded  into  a  small  space,  may  produce  a  complete 
hemiplegia. 

Monoplegias  are  frequent  symptoms  of  cortical 
lesions,  and  can  with  certainty  be  referred  to  this 
locality   when    symptoms    of   irritation    (convulsions) 

*  "Diseases  of  the  Nervous  System,"  Vol.  I,  1899,  p.  265. 


MISCELLANEOUS    CAUSES.  I  23 

appear  in  the  affected  parts.  Numerous  scientific 
teachings  show  that  such  centers  are  frequently  the 
seat  of  syphilitic  affections,  and  that  "cortical  epi- 
lepsy," as  stated  by  Lang,  of  Vienna,*  "is  grounded 
more  frequently  in  syphilis  than  in  any  other  cause." 
Minute  descriptions  of  such  cases  have  been  made  by 
Charcot.  Convulsive  phenomena  due  to  syphilitic 
poisoning  are  far  more  common  among  men  than 
among  women,  occurring  in  the  former  usually  be- 
tween the  thirtieth  and  fiftieth  year,  though  there 
may  be  exceptions  either  way. 

The  writer  has  at  present  under  his  care  a  man  of 
fifty  years,  whose  attacks  developed  at  forty-seven 
as  the  result  of  syphilis,  the  lesion  being  so  extensive 
as  to  affect  the  frontal  lobes  in  part,  either  organically 
or  by  implication,  as  shown  by  the  occurrence  of 
purely  psychic  attacks  of  the  disease.  He  also  has 
severe  attacks  of  grand  mat. 

A  young  farmer  of  thirty  years  had  frequent  at- 
tacks of  monoplegia  and  transitory  motor  aphasia  as 
the  result  of  the  same  cause.  He  most  frequently 
suffered  the  loss  of  the  use  of  the  right  hand  and  arm, 
and  it  was  common  for  him  to  drop  his  knife  and  fork 
at  the  table,  being  able  to  use  them  again  in  a  few 
moments  and  proceed  with  the  meal  as  usual. 

Almost  immediately  he  was  given  vigorous  anti- 
syphilitic  treatment,  and  these  temporary  mono- 
plegias disappeared.  His  extreme  mental  sluggish- 
ness left  him;  he  was  able  to  go  into  the  field  and 
work,  and  he  took  an  active  interest  in  his  surround- 
ings. On  stopping  the  treatment  for  two  or  three 
weeks,  the  spasms,  the  stupor,  the  inability  to  work, 
the  drawling,  hesitating  speech,  all  came  back,  only 
to  again  disappear  under  another  course  of  treatment. 

I  had  never  before,  and  have  not  since,  seen  a  case 
in  which  mercury  and  the  iodids  so  quickly  and  effec- 

*  "Twentieth  Century  Practice  of  Medicine,"  Vol.  xvm. 


124  ETIOLOGY. 

tually  swept  away,  at  least  for  the  time  being,  the 
results  of  syphilitic  disease  in  the  brain.  When  I  last 
saw  the  man  at  the  end  of  a  two  years'  course  of 
treatment,  he  was  in  excellent  condition  and  on  the 
point  of  returning  to  his  home  cured.  He  had  been 
committed  as  insane  because  of  marked  psychic  dis- 
turbances due  to  the  same  thing  that  caused  his 
convulsions. 

Bosworth  *  cites  Weber  as  reporting  two  cases  of 
infantile  syphilis  in  which  epileptic  convulsions  fol- 
lowed by  coma  developed  coincidently  with  the  cessa- 
tion of  the  sanious  discharge  from  the  nose;  the 
nervous  symptoms  disappeared,  however,  immediately 
upon  the  reestablishment  of  the  escape  of  pus  from 
the  nose. 

Bosworth  thinks  it  fair  to  assume  septic  infection 
in  such  cases,  though  he  appears  to  believe  that  the 
convulsions  are  more  likely  due  to  the  irritation  of 
the  dried  secretions  retained  in  the  nose. 

Sir  Morell  Mackenzie  refers  to  the  same  observa- 
tions made  by  Weber. 

Shock  from  Electricity. — In  two  cases  that  I  have 
seen,  shock  from  electricity  helped  to  establish  the 
disease.  In  one  case  the  subject  was  a  boy  of  fourteen 
years,  who  had  "some  convulsions  at  the  time  of  the 
first  dentition  at  seven  months,"  and  it  might  appear 
that  the  electric  shock  during  his  fourteenth  year  only 
served  to  again  develop  a  disease  that  had  previously 
existed,  though  it  is  also  fair  to  assume  that  the 
attacks  might  never  have  recurred  had  it  not  been 
for  the  electric  shock. 

The  second  case  occurred  in  a  man  at  the  age  of 
thirty- two,  who  had  long  suffered  from  rheumatism, 
having  a  marked  degree  of  "rheumatoid  deformans" 
affecting  the  back.  He  never  had  a  convulsion  of  any 
kind  prior  to  the  electrical  shock.     He  had  measles  at 

♦  "Diseases  of  the  Nose  and  Throat,"  1S93,  p.  362. 


MISCELLANEOUS    CAUSES.  125 

five  years  and  diphtheria  at  seventeen  years;  he  was 
always  temperate  in  his  habits.  Passing  along  the 
street,  he  saw  a  man,  engaged  in  trimming  an  arc 
lamp,  suddenly  grasp  the  wries  about  the  lamp  firmly 
and  stiffen  out.  *  The  patient  ran  out  to  assist  him 
and  immediately  upon  touching  the  man  through 
whom  the  current  was  going,  he  was  thrown  violently 
to  the  ground  several  feet  away.  He  felt  bruised  and 
sore  for  several  days,  and  shortly  after  had  the  first 
convulsion.  His  attacks  are  varied  in  character,  being 
both  grand  mal  and  psychic.  After  the  latter,  which 
predominate,  he  is  often  automatic  for  half  an  hour 
or  an  hour  at  a  time. 

Heart  Disease. — In  a  careful  physical  examination 
of  1070  cases  of  epilepsy  due  to  all  causes  and  embrac- 
ing all  ages,  I  was  struck  with  the  undue  proportion 
of  functional  and  organic  heart  lesions  encountered, 
which  were  classified  as  follows : 

Mitral  regurgitation  in 77 

Irregular  cardiac  force  and  rhythm  in 75 

Cardiac  hypertrophy  in 50 

Roughened  first  sound  in 13 

Systolic  murmur  at  apex  in 10 

Aortic  regurgitation  in 9 

Mitral  stenosis  in 2 

Tricuspid  regurgitation  in 1 

Diastolic  apex  murmur  in 1 

This  makes  a  total  of  238  who  presented  evidences 
of  some  form  of  heart  disease  or  irregularity,  though 
slight  in  many  cases. 

We  must  not,  however,  for  a  moment  assume  that 
the  epilepsy  in  all  these  cases  was  due  to  the  condition 
of  the  heart.  On  the  contrary,  in  my  opinion,  we 
may  lay  the  cause  of  many  of  the  heart  troubles  to 
the  effects  of  epilepsy,  while  in  other  instances  they 
were  present  merely  as  coincidences. 

I  believe  that  epileptics  are  unusually  prone  to 
diseases  of  the  heart  and  lungs ;   and  whoever  has  the 


126  ETIOLOGY. 

opportunity  for  witnessing  large  numbers  of  epileptic 
seizures  of  the  worst  type,  especially  during  the  tonic 
stage,  the  stage  of  the  single  prolonged  contraction, 
when  respiration  is  suspended  and  the  heart  is  under 
an  enormous  physical  strain,  will  soon  find  himself 
wondering  why  more  epileptics  do  not  die  during  the 
seizure  from  the  "  locking  up"  of  the  respiratory  act, 
or  from  the  forceful  damming  back  of  the  blood  upon 
the  heart,  with  consequent  injury  to  that  organ. 

There  are  cases,  however,  in  which  the  heart  lesion 
precedes  and,  in  all  probability,  causes  the  epilepsy, 
though  such  cases  are  rare.  Most  of  them  occur  late 
in  life,  more  frequently  among  men  than  women,  and 
they  are  nearly  always  associated  with  atheromatous 
changes.     Some  occur  in  childhood. 

In  all  probability  some  of  the  cases  of  organic  heart 
trouble  named  above  cause  the  epilepsy. 

I  recall  two  cases  in  which  the  subjects  were 
young,  both  boys,  one  nine  and  the  other  eleven 
years,  in  which  distinct  mitral  heart  lesions  existed  at 
the  beginning  of  the  epilepsy.  One  had  grand  mal, 
and  the  other  petit  mal  attacks.  The  father  of  one 
was  markedly  alcoholic,  the  other  rheumatic,  though 
neither  patient,  so  far  as  could  be  learned,  had  ever 
had  rheumatism. 

The  first  time  I  examined  the  one  who  had  petit 
mal,  I  had  opportunity  for  witnessing  a  seizure.  I 
had  just  asked  the  boy  to  stand  in  front  of  a  window 
that  I  might  see  his  eyes  better,  and  had  taken  hold 
of  both  his  wrists,  when  a  sudden  change  occurred  in 
his  expression,  some  drawing  down  and  slight  twitch- 
ing of  the  muscles  about  the  corners  of  the  mouth,  a 
set,  staring  expression  of  the  eyes,  both  pupils  being 
slightly  contracted;  there  was  a  little  hardening  of 
the  muscles  in  both  forearms,  and  the  head  was  gently 
turned  to  the  right.  In  less  than  two  seconds  the 
attack  had  passed,  and  the  boy  was  himself  again  at 
once. 


MISCELLANEOUS    CAUSES.  1 27 

The  pulse,  which  happened  to  be  under  my  touch 
at  the  time,  was  not  more  than  50  a  minute,  while 
half  an  hour  later  it  had  gone  up  to  its  normal  rate 
of  60. 

The  other  boy  had  a  similar  heart,  his  pulse-rate 
during  the  inter-paroxysmal  period  being  from  56 
to  60. 

The  most  rigid  search  failed  to  reveal  any  other 
cause  for  the  disease  in  the  two  cases,  both  having 
good  family  histories,  except  as  noted  above,  and  we 
felt  convinced  that  the  heart  lesion  in  each  case  was 
the  cause  of  the  epilepsy.  This  view  was  later  strength- 
ened after  the  condition  of  both  patients  had  im- 
proved under  treatment  directed  to  the  heart  dis- 
ease. 

F.  Savary  Pearce  *  reports  several  cases  which  tend 
to  reinforce  the  similarity  between  epileptoid  phe- 
nomena and  syncopal  attacks  that  are  independent 
of  the  epileptic  neuroses,  and  calls  attention  to  the 
full,  slow  pulse,  with  or  without  loss  of  consciousness, 
as  tending  to  confirm  the  epileptic  state. 

Pearce  is  of  the  opinion  that  "organic  disease  of 
the  heart  rarely  causes  convulsions." 

Chadbourne  f  deals  with  the  subject  in  extenso, 
quoting  Littre,  Delasiauve,  Tyson,  Boyce,  Gibbings, 
Bristowe,  R.  L.  Jones,  and  others  as  supporting  the 
belief  that  diseases  of  the  heart  may  cause  epilepsy; 
or,  as  some  of  these  authorities  state,  particularly 
Balfour,  pseudo-epileptiform  attacks  or  spasms. 

The  English  writers  particularly  tend  to  associate 
the  slow  pulse  and  epilepsy,  while  R.  L.  Jones  reports 
a  case  "in  which  mitral  regurgitation  and  slow  pulse 
coexisted  with  epileptic  attacks,  and  in  which  the 
infrequence  of  the  pulse  was  thought  to  have  been 
of  neuropathic  origin." 

*  "Annals  of  Gynecology  and  Pediatry,"  Nov.,  1900. 

t  "American  Journal  of  the  Medical  Sciences,"  March,  1902,  p.  461. 


128  ETIOLOGY. 

Hebb*  states  that  while  he  was  listening  to  the  heart 
of  a  patient  twenty-nine  years  of  age,  who  suffered 
from  aortic  insufficiency,  he  suddenly  became  aware 
that  the  heart  had  stopped  beating,  and  immediately 
a  general  convulsion  ensued  which  lasted  several 
minutes.  After  consciousness  returned,  the  patient 
talked  rationally  and  coherently  and  arose  without 
the  slightest  difficulty.  He  had  suffered  in  like 
manner  several  times  before. 

George  Lemoine  in  1887  published  an  article  en- 
titled L' 'epilepsie  d'origine  cardiaque  et  son  traite- 
ment,  this  writer  being  a  most  outspoken  advocate  of 
cardiac  disease  as  a  cause  of  epilepsy. 

After  carefully  reviewing  the  work  of  many  writers, 
Chadbourne  reports  eleven  cases  of  cardiac  disease 
associated  with  epilepsy,  with  autopsy  findings  in 
some  of  them,  concluding  as  follows:  "We  have  been 
unable  in  any  of  our  cases  to  show  to  our  satisfaction 
that  there  was  any  direct  connection  between  the 
vascular  lesions  and  epilepsy." 

Notwithstanding  the  failure  to  establish  a  causal 
relationship  between  cardiac  diseases  and  epileptic 
convulsions,  the  fact  remains  that  we  are  still  unable 
to  say  that  such  a  connection  does  not  exist.  The 
true  lesion,  or  the  precise  mechanism  by  which  the 
fit  is  brought  about  in  such  cases  may  not  be  capable 
of  material  demonstration  on  the  post-mortem  ex- 
amination. It  may  lie  rather  within  the  superior 
domain  of  some  other  field  of  science — perhaps  in  a 
combination  of  factors,  like  chemical  pathology,  like 
changes  in  the  blood,  or  a  functional  neurosis  confined 
to  the  heart  alone,  and  irregularity  in  physiologic 
action — all  founded  primarily  upon  the  diseased  con- 
dition of  the  heart,  or  upon  the  same  influence  that 
wrought  such  disease,  for  we  must  not  forget  the  pos- 
sible influence  of  rheumatism  or  other  constitutional 
states  in  this  respect. 

*  "American  Medicine,"  Vol.  I,  p.  174. 


MISCELLANEOUS    CAUSES.  129 

T.  S.  H.,  an  intelligent  business  man  of  fifty -three 
years,  of  good  physique,  and  fond  of  gratifying  an 
unusually  large  appetite,  remembers  having  a  single 
convulsion  at  the  age  of  eight  years,  which  he  says 
was  caused  by  eating  some  kind  of  poisonous  roots  in 
the  woods  when  he  was  looking  for  nuts. 

He  had  no  other  convulsion  until  he  was  fifty-three, 
when,  after  a  particularly  hard  day's  work  at  the  end 
of  a  busy  season,  one  appeared,  to  be  followed  a  year 
later  by  another  similar  in  character,  and  six  months 
later  by  a  third,  the  latter  occurring  abroad,  where 
the  patient  had  gone  for  rest  and  recuperation. 

I  found  his  arteries  as  hard  as  whip-cords,  those  in 
the  temples  standing  out  in  tortuous  outline,  barely 
compressible  under  the  finger.  There  was  a  distinct 
murmur  at  the  base  of  the  heart,  and  he  occasionally 
had  symptoms  of  false  angina. 

His  convulsions  were  attended  with  the  utmost 
distress  in  the  cardiac  region,  the  patient  declaring 
that  he  felt  "every  moment  must  be  his  last."  This 
distress  lasted  in  a  lessening  form  from  two  to  three 
days  after  the  seizure. 

The  attacks  were  always  grand  mal,  with  the  usual 
grand  mal  accompaniments,  including  the  biting  of 
the  tongue.  I  could  not  rid  my  mind  of  the  conviction 
that  dietetic  errors  had  much  to  do  in  the  immediate 
excitation  of  the  convulsions,  though  there  was  no 
question  in  my  own  mind  as  to  the  part  played  by  the 
organo-neurotic  lesion  in  the  heart  in  producing  the 
marked  symptoms  of  distress  followed  by  convulsions. 
The  point  in  this  case  is  this :  Although  this  man  had 
arteriosclerosis  in  a  marked  form,  he  would  not  ap- 
parently have  had  any  epileptic  convulsions  had  they 
not  been  immediately  excited  through  some  gastric 
disorder,  for  the  correction  of  this  condition  vastly 
improved  him  in  every  respect,  checking  the  seizures 
and  lessening  the  cardiac  distress. 

Gowers  states  that  an  abnormal  condition  of  the 
heart  is  met  with  in  many  cases,  though  not  in  sufficient 
number  to  indicate  a  definite  relation  to  the  disease, 
and  that  the  imperfect  supply  of  blood  to  the  brain  in 
diseases  of  the  heart  assists  in  the  degradation  of 
9 


130  ETIOLOGY. 

function  and  nutrition,  but  that  the  heart  disease  only 
becomes  effective  in  producing  epilepsy  in  the  pres- 
ence of  congenital  defect,  or  of  a  powerful,  acquired 
disposition. 

I  do  not  doubt  the  force  of  the  latter  condition  in 
the  slightest;  at  the  same  time  I  believe  that  some 
forms  of  heart  disease  are  capable  of  inducing  epileptic 
phenomena,  independent  of  predisposition  of  any 
kind. 

The  Influence  of  Sleep. — The  idea  of  attributing  to 
sleep  the  power  of  so  often  inducing  epileptic  convul- 
sions belongs  chiefly  to  Voisin  and  Lesague,  the  matter 
being  treated  thus  by  Voisin  under  Causes  determi- 
nantes:  "Among  the  determining  causes,  sleep  is  with- 
out doubt  the  most  frequent.  All  writers  agree  on  this 
subject.  Lesague  was  so  much  convinced  that  sleep 
was,  so  to  speak,  a  component  part  of  the  epileptic 
attack  that  he  expressed  the  opinion  that  any  noctur- 
nal convulsive  attack  was  of  epileptic  origin.  Accord- 
ing to  him,  hysterical  attacks  occurred  only  by  day." 

To  some  extent  what  these  writers  say  is  true, 
though,  in  my  opinion,  they  credit  sleep  with  inducing 
the  convulsion  more  often  than  facts  seem  to  prove. 
In  one  series  of  99,144  convulsions  which  occurred  in 
800  cases  at  the  Craig  Colony  during  the  year  1902, 
the  men  had  29,754  during  the  day  and  29,070  during 
the  night;  the  women  24,649  during  the  day,  and 
15,671  during  the  night,  making  a  total  in  the  two 
sexes  of  54,403  by  day  and  44,741  by  night. 

In  some  cases  in  which  the  attacks  occur  only  by 
night,  the  influence  is  due  to  sleep  itself,  while  in 
others  the  explanation  is  to  be  sought  in  the  bodily 
condition — -the  state  of  the  vital  processes — at  a 
period  when  physiologic  resistance  has  reached  its 
lowest,  ebb.  In  the  latter  cases,  the  attacks  come  on 
in  the  early  morning  between  two  and  six,  most  com- 
monly about  three ;  in  the  former  they  appear  as  soon 


SPORADIC    CAUSES.  131 

as  the  patient  falls  asleep.  We  have  seen  such  cases 
in  which  the  sleep  state  always  induced  the  convulsion, 
appearing  even  when  the  patient  slept  during  the  day ; 
in  other  cases  it  appeared  only  at  night. 

A.  Pick*  gives  some  interesting  measurements  of 
the  blood  pressure  during  sleep,  in  an  attempt  to  draw 
some  conclusions  from  them  with  reference  to  noctur- 
nal epilepsy.  He  makes  the  statement  "that  two- 
thirds  of  all  epileptic  attacks  are  apt  to  occur  in  sleep, 
most  of  them  either  with  the  first  hour  of  sleeping  or 
during  the  first  hour  before  waking. ' ' 

It  seems  logical  to  infer  that  nocturnal  seizures 
must  be  due  in  large  part  to  the  silent  processes  going 
on  even  when  we  sleep,  the  processes  concerned  in  the 
nutrition  of  the  body. 

There  can  probably  be  no  fit  without  irritation  of 
some  kind  in  highly  organized  nervous  tissue  or  centers 
somewhere,  and  seemingly  the  only  avenues  by  which 
irritation  can  reach  such  tissue  or  centers  during  sleep 
are  the  blood  and  the  sensory  nervous  system  in  some 
of  its  parts,  particularly  the  parts  of  the  latter  that 
influence  the  action  of  certain  viscera  which  are  inti- 
mately concerned  with  the  functions  of  digestion, 
absorption,  assimilation,  and  reconstruction. 

It  is  interesting  to  note  a  fact  here,  which  we  refer 
to  more  fully  in  the  chapter  on  Treatment,  namely, 
that  while  the  number  of  attacks  among  the  men  by 
day  and  by  night  were  almost  equal — 29,754  and 
29,070,  respectively — there  was  a  marked  dispro- 
portion in  the  same  figures  in  the  women,  for  out  of  a 
total  of  40,320  seizures  in  this  sex,  24,649  of  them 
occurred  during  the  day  and  15,671  during  the  night. 

SPORADIC  CAUSES. 

We  may  now  briefly  study  a  few  factors  that  infre- 
quently lead  to  the  disease,  among  them  being  hyper- 

*  "Wiener  medicinische  Wochenschrift,"  1899,  No.  30. 


132  ETIOLOGY. 

trophy  of  the  brain  and  hydrocephalus,  which  two  con- 
ditions should  not  be  confounded.  The  former  may 
be  general  or  partial.  Its  cause  is  obscure,  depending, 
according  to  Yirchow,  on  an  increase  in  the  neuroglia 
or  connective  tissue;  while  Rokitansky  thinks  the 
increased  size  is  due  to  an  increase  in  the  immediate 
granular  matter. 

In  two  autopsies  made  by  Andral,  the  white  matter 
resembled  "the  white  of  an  egg  hardened  by  boiling." 
As  a  rule,  such  brains  are  anemic,  and  Andral  states 
that  the  disease  has  two  periods,  the  first  in  which  the 
condition  is  chronic;  the  second,  that  of  convulsions 
which  generally  end  fatally. 

Such  brains  on  an  average  weigh  from  ten  to  fifteen 

ounces  more  than  the  average  weight  of  normal  brains. 

Jacobi*   speaks  of  this  condition  at  some  length, 

describing  a  case  with  convulsions  which  came  under 

his  observation. 

Hydrocephalus  was  the  cause  in  one  case  in  the 
1322  which  have  come  under  my  care;  the  hydro- 
cephalic condition  was  congenital,  the  convulsions 
developed  at  the  eighth  year. 

This  patient  had  a  mild  degree  of  internal  strabis- 
mus, the  treatment  of  which  did  not  have  any  effect 
on  his  seizures. 

Prenatal  ossification,  independent  of  such  degenera- 
tive mental  states  as  idiocy  and  imbecility,  rarely 
causes  epilepsy,  though  epilepsy  is  frequently  found 
in  connection  with  such  mental  states. 

Jacobi,  who  has  given  much  earnest  study  to  the 
causes  of  epilepsy  in  the  young,  says :  "  Cases  in  which 
epilepsy  of  later  years  is  due  extensively  to  the  com- 
pression of  an  originally  normal  brain  in  an  abnorm- 
ally compact  and  uniformly  contracted  skull,  I  have 
seen-;  but  more  are  due  to,  or  connected  with,  a  pre- 
mature partial  synostosis.     It  is  the  fate  of  a  great 

*  "American  Medicine,"  Dec.  13,  1902. 


SPORADIC    CAUSES.  133 

many  epileptics  to  have  a  comparatively  small  cranial 
circumference  and  an  absolutely  asymmetrical  shape." 

Focal  lesions  of  the  central  nervous  system,  indepen- 
dent of  trauma,  also  play  a  small  part  in  the  pro- 
duction of  epilepsy.  These  include  lesions  of  vascular 
origin,  such  as  softening,  abscess,  atrophy,  sclerosis, 
and  brain  tumors,  which  in  the  majority  of  instances 
are  either  sarcomata  or  gliomata ;  the  harder  varieties 
that  spring  from  bone  and  fibrous  tissue  are  also  some- 
times found. 

The  form  and  degree  of  convulsions  due  to  focal 
organic  diseases  in  the  brain  depend  upon  the  nature, 
location,  and  character  of  the  lesion.  This  much  may 
be  said  in  general  of  epilepsies  that  follow  such  causes : 
They  are  apt  to  remain  circumscribed  in  their  field  of 
action  and  rarely  affect  the  mind  to  any  appreciable 
extent,  unless  the  organs  of  the  mind  are  directly 
involved. 

Asphyxia  of  the  new-born  has  already  been  men- 
tioned among  the  accidental  causes  of  that  period, 
but  asphyxiation  of  other  kinds  may  produce  epilepsy, 
one  man  having  come  under  my  care  who  was  poisoned 
by  coal-gas  and  whose  convulsions  developed  im- 
mediately thereafter.     . 

Extreme  fatigue  may  safely  be  put  down  as  the 
determining  cause  of  attacks  in  some  who  already 
have  epilepsy,  but  we  hesitate  to  claim  that  it  alone 
ever  produces  the  disease  de  novo. 

I  recall  the  case  of  a  prominent  merchant  whose 
business  kept  him  hard  at  work  on  Saturday  nights 
until  eleven  o'clock  or  later.  He  lived  across  the 
street  from  my  office,  and  five  weeks  in  succession 
I  was  called  between  one  and  two  o'clock  in  the  morn- 
ing to  attend  him  in  convulsions.  On  giving  up  the 
hard  night-work,  his  attacks  entirely  ceased. 

He  was  thirty-two  years  of  age,  and  was  a  fine  speci- 
men of  physical  manhood;    he  had  no  harmful  prac- 


134  ETIOLOGY. 

tices  of  any  kind,  but  possessed  a  highly  sensitive 
nervous  organization  and  was  subject  to  "nervous 
headaches." 

Brietung*  reports  the  case  of  a  boy,  sixteen  years 
of  age,  who  ran  a  long  distance  on  a  hot  afternoon  in 
July  to  take  a  cold  water  douche  on  his  head,  re- 
maining under  it  a  quarter  of  an  hour.  Soon  after 
it  was  noted  that  he  was  unusually  excited,  and  during 
the  night  which  followed  he  showed  great  restlessness. 
The  following  morning  an  attack  consisting  of  "jac- 
titations, unconsciousness,  etc,"  came  on,  which 
lasted  some  time,  and  was  pronounced  epileptic  by 
the  attending  physician.  From  that  time  on  the 
convulsions  appeared  from  six  to  eight  times  a  year, 
each  being  preceded  by  motor  aura  in  the  left  hand 
and  stimulation  of  the  sexual  impulse. 

Brietung  regarded  the  cold  douche  on  the  boy's 
head  as  a  traumatism  causing  the  epilepsy. 

The  train  of  symptoms  induced  by  phimosis,  con- 
genital or  acquired,  may  lead  to  reflex  epilepsy, 
either  through  masturbation,  of  which  we  have  pre- 
viously spoken,  or  through  excessive  irritation. 

I  saw  a  girl  nine  years  old  whose  epileptiform  con- 
vulsions were  due  to  a  stricture  of  the  urethra,  as  was 
proved  by  their  cessation  when  the  stricture  was  cut. 

A  boy  had  a  convulsion  at  the  age  of  one  year 
which  lasted  four  hours,  and  had  no  further  trouble 
of  the  kind  until  he  reached  the  age  of  eleven,  when 
he  was  vaccinated,  and  his  body  became  covered  with 
a  "general  scaly  eruption."  The  convulsions  which 
appeared  immediately  after  became  permanent  in 
character. 

A  young  man,  who  had  never  had  a  convulsion 
before,  was  severely  stung  by  bees  about  the  face,  and 
convulsions  appeared  with  much  regularity  every 
two  weeks  thereafter. 

*  "Deutsche  medicinische  Wochenschrift,"  1898,  xxiv,  39. 


SPORADIC    CAUSES.  135 

It  is  well  known  that  the  sting  of  this  insect  is 
poisonous  to  some  persons. 

It  is  claimed  that  hypertrophy  of  the  Schneideriau 
membrane,  nasal  and  nasopharyngeal  growths,  renal 
and  vesical  calculi,  and  various  forms  of  intestinal 
helminthes,  from  tinea  to  oxyuris,  cause  epileptiform 
convulsions.  Worms  were  the  ascribed  cause  in  only 
two  of  the  author's  cases. 

As  to  the  influence  of  the  latter  in  a  few  favorable 
cases  in  causing  convulsions,  there  seems  to  be  no 
doubt,  though  in  such  cases  the  cause  probably 
lies  as  much  in  the  general  derangement  of  the  in- 
testinal tract  as  in  the  presence  of  worms  themselves. 
It  is  unfortunate  that  worms  are  so  often  credited 
with  causing  convulsions.  I  have  seen  cases  in  which 
the  treatment  based  on  such  a  supposition  did  the 
child  immense  harm,  while  the  spasms  were  found 
later  on  to  be  due  to  other  causes. 

I  have  never  witnessed  convulsions  due  to  foreign 
growths  in  the  nose,  or  to  enlargement  of  any  of  its 
parts,  though  cases  have  been  reported  in  which  it 
was  claimed  that  the  removal  of  such  agencies  checked 
the  convulsive  attacks. 

Such  a  case  was  reported  by  Grasskopf.*  The 
patient,  twenty  years  old,  had  suffered  from  con- 
vulsions for  a  year,  which  finally  appeared  several 
times  a  day.  Treatment  with  the  bromids  did  no 
good.  There  was  suppuration  in  the  antrum  of 
Highmore,  and  some  nasal  polypi,  and  the  patient 
had  a  seizure  during  the  operation  for  the  cure  of  these 
conditions,  but  none  have  appeared  subsequently. 
The  report  does  not  state  how  long  after  the  opera- 
tion the  patient  became  free  from  attacks,  and  it 
seems  difficult  to  say  which  of  the  conditions  present 
caused  the  convulsions. 

*  "Archiv.  fur  Laringologie,"  xm,  1;  "Berliner  klinische  Wochen- 
schrift,"  Aug.  4,  1902. 


136  ETIOLOGY. 

Richardson*  reports  the  case  of  a  boy  with  a  hyper- 
sensitive nasal  passage  and  marked  hypertrophy  of 
the  middle  and  inferior  turbinated  bones,  the  relief 
of  which  checked  the  convulsions,  which  had  not 
recurred  eight  months  later. 

Kahnj  reports  the  case  of  a  man  subject  to  nose- 
bleed, who,  on  one  occasion  when  bleeding  was  quite 
persistent  from  a  small  eroded  spot,  was  locally  treated 
by  the  application  of  a  10  per  cent,  solution  of  cocain, 
with  the  extraordinary  result  that  the  "patient 
became  deathly  pale  and  somewhat  cyanosed;  he 
had  twitching  of  the  facial  muscles,  and  fell  to  the 
floor  comatose;  then  he  was  seized  with  convulsions 
of  the  most  marked  epileptiform  character,  the  con- 
vulsive movements  affecting  the  right  half  of  the  body 
more  than  the  left." 

The  author  thinks  that  the  anemic  condition  of  the 
patient  due  to  loss  of  blood  may  have  contributed 
largely  to  the  production  of  the  fit,  and  states  that 
convulsions  from  cocain  have  been  reported  both  by 
Curgenven  and  by  Garland,  the  former  having  wit- 
nessed convulsions  after  the  ingestion  of  ten  grains 
of  the  salt  by  the  mouth ;  the  latter,  convulsions  and 
death  after  fifteen  grains,  taken  in  the  same  way. 

Eye-strain  has  long  occupied  debatable  ground  as  a 
possible  cause  of  epilepsy.  In  the  large  number  of 
cases  which  it  has  been  my  privilege  to  study — some 
1800  all  told — I  am  unable  to  recall  a  case  in  which 
I  felt  the  whole  cause  to  lie  in  any  anomalous  con- 
dition of  the  visual  apparatus. 

Stevens's  essay  on  "  Functional  Nervous  Diseases," 
which  was  honored  with  a  prize  by  the  Royal  Academy 
of  Medicine  of  Belgium  in  1883,  contains  recitals  of 
ocular  conditions  found  in  140  cases  of  epilepsy, 
which  he  described  as  follows: 

*  "Medical  Record,"  July  14,  1900. 
f  "Medical  Record,"  March  24,  1900. 


SPORADIC    CAUSES.  137 

"The  general  results  of  these  examinations  have 
been  to  reveal  the  existence  of  refractive  anomalies 
in  a  considerably  greater  proportion  than  has  been 
found/ by  Cohn  in  his  examinations  of  the  eyes  of 
school  children,  or  by  other  observers  in  similar 
investigations  in  Germany,  Russia,  and  America." 

In  ioo  consecutive  cases,  Stevens  found  hyper- 
metropia,  with  hypermetropic  astigmatism  in  59; 
myopia  with  myopic  astigmatism  in  23;  and  em- 
metropia,  or  refractive  errors  less  than  one  dioptric, 
in  18. 

Stevens  claims,  in  the  same  essay,  that  muscular 
insufficiencies  of  the  ocular  apparatus  are  potent 
factors  in  the  development  of  epilepsy,  bringing  for- 
ward a  number  of  instances  in  support  of  this  view. 

Ranney*  refers  to  work  done  by  himself  in  1897  in 
preparing  a  special  volume  on  ' '  Eye-strain  in  Health 
and  Disease,"  in  which  he  makes  some  very  remark- 
able statements  concerning  the  good  results  secured 
in  treating  epilepsy  through  the  eye  alone. 

Gouldf  is  likewise  convinced  that  eye-strain  has  an 
important  place  in  the  etiology  of  epilepsy,  and  in  the 
chapter  on  Treatment  we  refer  in  detail  to  the  work 
of  this  distinguished  ophthalmologist  at  Sonyea  in 
the  treatment  of  sixty-eight  cases  through  the  careful 
correction  of  errors  in  refraction. 

In  "American  Medicine  "  (July  5,  1902)  Gould  refers 
to  six  cases  of  epilepsy  due  to  ametropic  eye-strain, 
in  which  correction  of  the  condition  resulted  in  appa- 
rent cures  in  some,  in  improvement  to  others. 

He  says:  "That  epilepsy  has  been  caused  by  im- 
balance of  the  ocular  muscles  and  cured  by  operation 
has  been  asserted,  but  this  cannot  be  true,  if,  as  we 
believe,  the  incoordination  of  the  external  ocular 
muscles  is,  in  itself,  the  result  of  ametropia.     That 

*  "New  York  Medical  Journal,"  Nov.  22,  1902. 

t  "American  Medicine,"  Vol.  lv,  No.  i,  p.  2,  July  5,  1902. 


138  ETIOLOGY. 

ametropia  does  occasionally  cause  epilepsy  is,  I  think, 
beyond  question  by  those  who  have  studied  the  facts 
with  a  genuine  scientific  spirit." 

There  should  be  some  significance  in  the  fact  that 
not  once  do  we  find  eye-strain  or,  indeed,  visual  defect 
of  any  kind,  in  the  histories  of  1324  cases  admitted 
to  the  Craig  Colony  in  eight  years,  either  under 
"assigned  cause"  or  under  "probable  cause."  It 
may  be  claimed  by  some  that  general  practitioners 
and  neurologists  are  not  good  oculists  and  might  not 
be  able  to  locate  the  cause  of  epilepsy  in  the  eye,  even 
if  it  were  there. 

To  some  extent  this  might  be  true,  but  the  tendency 
of  the  day  is  so  strongly  toward  specialization,  and 
epilepsy  is  so  difficult  to  treat  in  a  way  to  yield  satis- 
factory results,  that  a  large  number  of  such  cases, 
prior  to  commitment  to  an  institution  such  as  the 
Craig  Colony,  are  subjected  to  the  crucial  tests  of  the 
ophthalmic  surgeon  as  well  as  to  specialists  along 
other  lines,  in  the  efforts  made  to  determine  the  cause 
of  their  attacks. 


CHAPTER  VI. 
SEIZURE  TYPES. 

The  Relative  Frequency  of  Different  Seizure  Types.  Descriptions  of 
Regular  and  Irregular  Forms  of  Each.  Grand  Mai.  Petit  Mai.  Psychic. 
Jacksonian.  Serial  Attacks.  Reflex  Epilepsy.  Epileptic  Equivalents. 
Partial  Epilepsy.  Tetanoid  Epilepsy.  Hystero-epilepsy.  Myoclonus 
Epilepsy. 

When  considering  the  nomenclature  of  seizure  types 
based  on  symptomatology,  reference  was  made  to 
some  of  the  more  prominent  features  of  the  many 
forms  of  epileptic  convulsions,  though  not  to  an  extent 
sufficient  for  diagnostic  purposes. 

Before  we  take  up  the  important  matter  of  diagnosis, 
we  should  possess  clear  ideas,  not  only  of  the  more 
prominent  and  regular  forms  of  the  disease,  but  of 
the  less  prominent  and  irregular  forms  as  well. 

I  know  of  no  studies  made  to  determine  the  com- 
parative frequency  of  seizures  of  different  types,  and 
while  it  cannot  be  claimed  that  the  results  obtained 
in  1325  cases  studied  in  this  respect  are  conclusive, 
they  are  offered  as  quite  accurately  indicating  the 
comparative  frequency  of  each. 

Seizures  of  the  grand  mal  type  are  far  more  common 
than  any  other.  In  the  1325  cases  mentioned,  815  of 
whom  were  men  and  510  women,  482  of  the  former  and 
292  of  the  latter  suffered  from  this  form,  making  about 
60  per  cent,  of  the  whole  number  who  had  grand  mal 
convulsions,  the  proportion  in  the  two  sexes  being 
substantially  the  same. 

In  the  same  cases,  38  men  and  34  women,  constitut- 
ing about  4%  per  cent,  of  the  former  and  6|  per  cent, 
of  the  latter,  had  petit  mal  alone ;   therefore  it  appears 

139 


140  SEIZURE    TYPES. 

that  more  women  than  men  suffer  from  this  lighter 
form  of  the  disease. 

Under  the  purely  psychic  form,  the  total  number  is 
still  less,  as  four  cases  only,  three  men  and  one  woman, 
are  classed  under  this  head.  This  does  not,  however, 
by  any  means  indicate  that  this  type  of  epilepsy  is  as 
rare  as  this  would  seem  to  make  it,  for  among  the 
mixed  types  to  be  noted  later  on,  it  is  comparatively 
common;  that  is,  the  same  individual  has  grand  mal 
and  psychic,  or  petit  mal  and  psychic,  as  the  case  may 
be,  the  former  combination  being  considerably  more 
frequent. 

The  four  cases  of  purely  psychic  epilepsy  mentioned 
were  uncomplicated  by  attacks  of  any  other  kind. 
We  should  also  bear  in  mind  that  the  unobtrusive 
character  of  psychic  epilepsy  makes  its  presence  pos- 
sible for  an  indefinite  period  of  time  before  its  existence 
is  known  to  any  but  the  patient  himself,  and  doubtless 
many  cases  of  it  go  continuously  unrecognized. 

Jacksonian  epilepsy  is  nearly  twice  as  commonly 
met  with  as  psychic  epilepsy;  there  were  nine  such 
cases,  six  men  and  three  women,  among  the  1325 
studied. 

It  is  my  belief  that  Jacksonian  epilepsy,  in  which 
the  attacks  not  only  begin,  but  end  as  such,  is  extremely 
rare.  It  is  not,  however,  an  uncommon  thing  to  find 
attacks  that  assume  this  form  in  the  beginning  only 
to  run  into  general  epilepsy  before  the  fit  is  over. 
In  the  nine  cases  mentioned  here,  the  type  was  pre- 
served pure  throughout  the  seizure. 

Cases  in  which  the  convulsions  are  mixed  in  char- 
acter stand  next  in  frequency  to  grand  mal,  and  we 
note  that  286  of  the  815  men  and  180  of  the  510  women 
— constituting  in  the  two  sexes  combined  about  32 
per  cent,  of  the  entire  number — suffered  from  mixed 
forms  of  the  disease. 

There  is  no  fixed  rule  or  order  observed  in  the  mixing 


CASES    OF    GRAND    MAL    EPILEPSY.  141 

of  types  in  the  same  individual,  though,  as  we  have 
previously  stated,  grand  mal  and  petit  mat  are  more 
often  noted  together  than  any  other,  the  very  probable 
reason  being  the  greater  frequency  of  these  forms 
individually  over  the-  other  two. 

It  must  also  be  borne  in  mind  that  fixity  of  type  is 
not  constant.  An  individual  may  suffer  from  grand 
mal  attacks  for  a  long  period  and  then  have  some  other 
form,  though  changes  in  this  respect  are  more  apt  to 
be  from  the  lighter  to  the  more  severe,  as,  for  instance, 
from  petit  mal  to  grand  mal,  or  from  Jacksonian  to 
grand  mal.  I  do  not  recall  a  case  in  which  Jacksonian 
seizures  were  replaced  by  those  of  a  psychic  nature; 
nor  have  I  ever  known  the  reverse  to  be  true.  At 
the  same  time,  such  a  possibility  cannot  be  denied. 

ILLUSTRATIVE  CASES  OF  GRAND  MAL  EPILEPSY. 
Under  this  I  shall  describe  both  regular  and  irregular 
forms  of  the  disease,  assuming  that  the  regular  or 
classical  convulsion  means  the  invariable  presence 
of  certain  features  during  the  attack;  the  irregular, 
the  absence  of  or  a  marked  variation  in  any  of  the 
pathognomonic  symptoms  present  under  the  former. 

Case  I. — M.  J.  O'T.  was  sitting  on  a  chair  when  the 
attack  began,  the  first  thing  unusual  being  a  short, 
low,  moaning  sound,  like  a  sigh.  The  patient  then 
moved  forward  to  the  edge  of  the  chair  as  though 
about  to  rise,  and  remained  "fixed"  in  this  position 
for  thirty  seconds;  during  this  time  his  face  was  pale, 
his  eyes  were  set  and  staring  directly  forward,  and  both 
hands  opened  and  closed  in  rapid  alternation.  Then 
his  eyes  began  to  move  slowly  upward  and  outward 
to  the  left,  and  when  they  had  completely  turned,  his 
head  began  to  turn  in  the  same  direction  and  went 
around  until  the  chin  was  almost  directly  over  the 
left  shoulder.  The  convulsive  movements  in  the 
hands  now  ceased,  and  both  remained  tightly  clinched 
in  clonic  contraction,  the  thumbs  being  tightly  flexed 


142  SEIZURE    TYPES. 

across  the  palms  with  the  fingers  over  it.  Suddenly 
the  body  lurched  forward  and  fell  to  the  floor,  striking 
partly  on  the  left  side  which  was  due  to  the  force  of 
the  contractions  in  that  direction.  Immediately  on 
striking  the  floor,  both  arms  were  drawn  upward  and 
apart,  the  forearms  being  flexed  on  the  arm,  and  the 
contraction  being  more  marked  on  the  left  side  than 
on  the  right.  Both  legs  were  drawn  upward  and  wide 
apart  at  the  knees,  and  the  lower  legs  were  sharply 
flexed  on  the  thighs,  this  condition  being  more  marked 
on  the  left  than  on  the  right  side;  both  feet  were 
turned  inward  at  the  ankle,  this  also  being '  more 
marked  on  the  left  than  on  the  right  side.  The 
mouth  was  open,  and  the  lower  jaw  was  drawn  forc- 
ibly downward  and  strongly  to  the  left. 

The  patient  remained  immovable  in  this  position 
during  the  stage  of  tonic  contraction,  which  lasted 
seventy  seconds,  when  the  stage  of  clonic  contraction 
set  in,  which  was  very  brief,  lasting  twelve  seconds; 
there  were  only  three  shock-like  contractions  during 
that  time,  these  appearing  most  marked  in  the  ex- 
tremities, and  of  equal  violence  in  all  parts;  all  con- 
vulsive movements  ended  with  the  last  of  these. 

The  period  of  stertor  that  followed  was  prolonged 
and  severe,  and  covered  three  minutes,  during  which 
time  a  large  amount  of  froth  was  blown  from  the  mouth 
at  each  expiration,  the  cheeks  being  forcibly  drawn 
in  and  forced  out  with  each  inspiration  and  expiration. 
When  these  movements  ceased,  the  patient  passed 
into  a  comatose  sleep  that  lasted  fifteen  minutes, 
after  which  he  sat  up  and  was  able  to  talk  in  a  confused 
way.  While  there  was  no  mental  disturbance  beyond 
this  slight  temporary  confusion,  he  was  greatly  ex- 
hausted physically  and  felt  indisposed  for  any  activity 
for  several  hours. 

In  this  case  the  tongue  was  not  bitten,  there  was 
no  aura  of  any  kind,  nor  was  the  so-called  epileptic 
cry  present ;  the  only  sound  which  escaped  the  patient 
was  the  low  moan  at  the  beginning — a  significant 
involuntary  expression  of  distress. 

Case, II.— J.  B.  was  sitting  on  a  chair  when  his  face 
was  observed  to  grow  suddenly  pale,  especially  about 
the   mouth.     The   blanching   grew   more   pronounced 


CASES    OF    GRAND    MAL    EPILEPSY.  143 

during  a  period  of  two  minutes,  and  the  patient 
remained    motionless    and    silent    during    that    time. 

Suddenly  he  threw  the  right  arm  above  his  head 
and,  without  any  cry,  fell  to  the  floor.  The  convulsive 
movements  began  in  the  right  hand,  the  fingers  closing 
on  the  palm  in  severe  clonic  contractions,  the  thumb 
being  inserted  at  each  contraction  between  the  index 
and  second  fingers.  Then  the  convulsive  movements 
appeared  in  the  forearm,  next  in  the  arm;  then  they 
involved  the  head,  passed  from  the  head  to  the  left 
hand,  then  up  to  the  left  forearm  and  arm,  jumped 
next  to  the  left  foot  and  passed  up  the  leg  to  the  body. 
The  left  hand  contracted  in  a  natural  way,  the  thumb 
being  outside  the  fingers  just  as  the  fist  is  closed 
preparatory  to  striking  a  blow.  The  head  was  turned 
to  the  left,  and  the  mouth  was  drawn  in  the  same 
direction,  the  jaws  opening  and  shutting  with  great 
violence. 

The  eyes  were  turned  upward  and  to  the  left,  when 
suddenly  a  single,  sharp  convulsive  movement  turned 
the  head  to  the  right,  the  mouth  and  eyes  being  drawn 
in  the  same  direction;  now  convulsive  movements 
began  in  the  foot,  and  rapidly  passed  up  the  leg,  but 
being  at  no  time  as  severe  as  in  the  other  parts  pre- 
viously affected. 

The  period  of  tonic  contraction  lasted  thirty  seconds, 
while  the  clonic  contractions,  which  were  general, 
consisted  of  a  series  of  shock-like  movements,  affected 
the  entire  body  at  once,  and  lasted  forty  seconds; 
the  right  arm  was  disturbed  by  disappearing  contrac- 
tions for  a  full  minute  after  muscular  composure  was 
elsewhere  complete. 

The  face  was  deeply  cyanotic  to  the  end ;  the  period 
of  stertor  was  prolonged;  the  pupils  were  widely 
dilated  throughout  the  seizure  and  unresponsive  to 
light.  The  salivary  flow  was  light;  the  tongue  was 
not  bitten;  the  urine  was  not  voided;  the  tempera- 
ture was  98. 8°;  the  pulse  68;  and  respiration  22;  all 
this  was  noted  immediately  after  the  convulsive  stage 
was  over,  and  before  the  stage  of  coma. 

The  patient  aroused  from  the  comatose  state  in  four 
minutes,  then  slept  soundly  for  twenty  minutes,  after 
which  he  was  substantial! v  in  his  normal  state. 


144  SEIZURE    TYPES. 

Case  III. — C.  S.  was  engaged  in  making  a  bed  when 
she  suddenly  stopped,  straightened  herself  up  and  ran 
five  yards,  when  she  fell  to  the  floor.  She  was  able 
to  speak  at  the  time,  and  complained  of  a  "crawling 
sensation"  in  the  pit  of  the  stomach.  The  sensation 
appeared  to  extend  gradually  upward  until  it  reached 
the  throat,  when  a  feeling  of  constriction  was  expe- 
rienced, and  the  patient  made  a  single,  loud,  sharp  cry, 
and  closed  tightly  both  eyelids  at  the  same  time. 

Her  face  wore  a  terrified  aspect  during  the  moment 
preceding  the  involuntary  closing  of  the  eyes.  The 
convulsive  movements  then  appeared,  beginning  in 
both  eyelids  and  extending  to  the  eyeballs,  which 
became  involved  and  turned  sharply  upward  and  to  the 
left.  The  face  began  to  assume  a  deep  cyanotic 
appearance.  The  left  hand  was  clinched  with  the 
thumb  over  the  fingers,  the  right  partly  so,  the  thumb 
being  caught  between  the   first   and  second  fingers. 

The  legs  were  flexed  on  the  thighs,  with  the  knees 
wide  apart.  This  position  of  tonic  contraction  lasted 
for  eighteen  seconds  and  was  followed  by  twelve  sharp, 
decisive,  clonic  spasms,  during  which  the  tongue  was 
protruded  between  the  teeth  and  severely  lacerated. 
At  the  end  of  the  clonic  spasms  the  patient  sank  into 
deep  coma  which  ended  in  sleep  that  lasted  for  three 
hours.  On  awaking  she  was  clear  mentally,  being  able 
to  recall  all  that  transpired  at  the  beginning  of  the 
attack  up  to  the  time  the  choking  sensation  reached 
the  throat,  just  prior  to  the  cry ;  after  which  all  was 
a  blank  until  she  awoke  from  the  sleep  three  hours 
later. 

As  soon  as  the  active  part  of  the  attack  was  over,  the 
temperature  was  99. 5°  F. ;  the  pulse  103,  and  res- 
piration 22.  She  complained  of  great  thirst,  general 
muscular  soreness,  headache,  and  nausea.  The  thirst 
was  due  in  part  to  the  profuse  sweating,  this  phe- 
nomenon being  at  times  excessive  just  after  the  periods 
of  contraction  and  stertor,  in  part  to  the  mild  degree 
of  post-convulsive  fever,  which,  as  a  rule,  is  of  short 
duration,  rarely  lasting  over  two  or  three  hours,  and 
generally  subsiding  in  less  time  than  that. 

Case  IV. — E.  Mc.  was  sitting  on  a  chair  with  her  arms 
folded,  when  she  suddenlv  screamed,  threw  both  arms 


CASES    OF    GRAND    MAL    EPILEPSY.  145 

over  her  head,  and  fell  face  downward  to  the  floor. 
There  was  no  aura  of  any  kind,  the  first  thing  noticed 
being  the  cry,  and  the  patient  simultaneously  falling 
to  the  floor.  She  was  immediately  turned  on  her  back, 
and  it  was  noted  that  the  face  was  pale  and  both  eyes 
were  tightly  closed.  Almost  at  once  they  began  to  open, 
turning  upward  and  to  the  left  at  the  same  time; 
then  convulsions  began  in  the  left  leg,  continued  up 
that  side,  and  involved  the  left  hand  and  arm;  they 
next  appeared  on  the  right  side  of  the  face,  drawing 
the  mouth  open  and  upward  to  the  left  side.  The  face 
became  more  deeply  cyanosed,  the  pupils  of  both  eyes 
were  widely  dilated,  and  the  corneal  reflex  was  entirely 
lost.  Both  legs  were  sharply  drawn  up;  the  legs 
flexed  on  the  thighs,  and  the  thighs  on  the  abdomen, 
the  knees  being  wide  apart.  The  left  arm  was  flexed 
tightly  against  the  chest ;  the  right  forearm  flexed  only 
part  way  on  the  upper  arm ;  both  hands  were  tightly 
closed,  the  thumbs  lying  over  the  fingers. 

In  this  position  the  tonic  spasm  lasted  seventeen 
seconds,  while  the  clonic  period  that  followed  lasted 
twelve  seconds;  the  convulsive  movements  of  this 
period  shaded  out  to  complete  composure  and  ter- 
minated in  a  few  deep  respiratory  movements  which 
expelled  froth  from  the  mouth.  At  the  end  of  the 
stertor  period,  the  temperature  was  99. 20  F. ;  the  pulse 
122,  and  respiration  26.  Urine  was  involuntarily 
voided  and  the  patient  remained  in  a  comatose  sleep 
for  thirty  minutes;  then  she  sat  up  .when  spoken  to, 
but  was  stupid  and  indifferent  to  her  surroundings. 
The  tongue  was  slightly  injured  during  the  clonic 
contractions. 

Case  V . — F.  C.  was  standing  unoccupied,  when  he 
suddenly  staggered  backward  two  or  three  steps, 
falling  heavily  to  the  floor  on  his  back.  The  first 
noticeable  contraction  occurred  in  the  right  thumb, 
extended  next  to  the  right  hand,  then  to  the  right  leg ; 
after  which  it  passed  over  to  the  left  side  involving 
the  hand  first,  then  the  arm,  then  the  leg,  and  finally 
the  face,  when  a  typical  epileptic  cry  was  given. 

Both  fists  were  tightly  clinched,  and  both  thumbs 
were  inserted  between  the  first  and  second  fingers. 
This  has  been  called  the  epileptic  hand.     Both  eyes 


146  SEIZURE    TYPES. 

were  rolled  up  and  to  the  right;  both  pupils  were 
widely  dilated,  and  the  conjunctivas  were  congested. 

During  the  clonic  stage  the  lids  opened  and  closed 
spasmodically.  The  face  was  deeply  flushed,  the  color 
shading  into  a  darker  cyanotic  hue  as  the  tonic  period 
became  prolonged. 

At  first  the  arms  were  extended  almost  at  right 
angles  to  the  body,  then  drawn  in  and  flexed  tightly 
across  the  chest.  The  legs  were  flexed  on  the  body. 
The  tonic  part  of  the  convulsions  lasted  forty  seconds, 
followed  by  the  clonic,  in  which  the  movements  of 
the  limbs  were  excessive,  the  patient  being  violently 
tossed  about  through  the  force  of  the  shock-like  mus- 
cular contractions.  This'  period  lasted  twenty-five 
seconds,  respiration  being  re-established  by  a  series 
of  deep,  stertorous,  blowing  sounds.  The  tongue  was 
severely  bitten  during  the  clonic  spasms,  and  the 
froth  which  was  expelled  with  each  noisy  expiration 
was  tinged  with  blood. 

Immediately  after  the  stertor  period  the  temperature 
was  990  P.;  the  pulse  135,  and  respiration  28.  The 
patient  fell  into  a  deep  sleep  which  lasted  two  hours 
and  a  half,  and  on  awakening  complained  of  a  severe 
headache  and  showed  great  irritability  of  temper. 

These  cases  suffice  to  give  a  fair  idea  of  the  grand 
mat  attack.  We  note  from  them  that  the  convulsive 
movement  may  begin  in  almost  any  part  of  the  body, 
though  it  most  often  begins  in  the  hand  or  leg;  that 
the  eyes  are  always  involved;  that  the  face  is  cya- 
notic, this  being  so  extreme  in  some  cases  as  to  cause 
it  to  be  almost  black.  All  reflexes  are  abolished. 
There  are  three  distinct  periods:  That  of  the  tonic 
contractions ;  that  of  clonic  contractions ;  and  that  of 
stertor  and  coma.  All  of  these  are  necessary  accom- 
paniments of  every  grand  mat  attack. 

The  direction  in  which  the  patient  falls  indicates 
in  a  measure  the  location  and  severity  of  the  muscular 
contractions.  Some  always  fall  straight  forward; 
others  to  one  side  or  the  other;  others  backward; 
while  still  others  sink  gradually  down  just  where  they 


CASES    OF    PETIT    MAL    CONVULSIONS.  147 

stand,  though  these  are  rarely  true  cases  of  uncompli- 
cated grand  mal  attacks.  Some  fall  so  persistently 
and  repeatedly  in  a  manner  to  strike  the  same  part 
of  the  body  every  time,  like  the  occiput,  the  outer 
angle  of  the  eyebrow,  or  the  point  of  the  chin,  that 
it  is  a  part  of  the  treatment  to  protect  these  places 
with  pads  to  break  the  force  of  the  fall. 

The  epileptic  cry  is  not  essential  in  every  convulsion, 
and  when  it  appears  it  is  due  to  one  of  two  things, 
very  possibly  to  both :  To  some  convulsive  disturbance 
in  the  speech  center,  or  to  the  forcible  expulsion  of  air 
from  the  chest,  through  the  contraction  of  its  muscular 
walls,  the  rushing  of  the  air  through  the  vocal  cords 
producing  the  inarticulate  sound.  Injury  to  the 
tongue  is  an  unessential  incident.  When  it  is  present, 
it  means  that  the  tongue  was  protruded  between  the 
teeth  during  the  period  of  clonic  contractions.  When 
not  present,  it  means  the  absence  of  muscular  action 
that  causes  protrusion  of  the  tongue  while  the  jaws 
are  opening  and  closing  spasmodically. 

ILLUSTRATIVE  CASES  OF  PETIT  MAL  CONVULSIONS. 

We  come  now  to  the  consideration  of  seizure  types 
that  are  distinguishable  from  the  form  just  described 
only  through  their  lessened  severity.  They  partake 
of  all  the  features  of  grand  mal  epilepsy,  including 
the  loss,  or  disturbance,  of  consciousness,  and  general 
muscular  commotion.  But  though  they  are  less 
severe,  they  have  the  appearance  of  disturbing  the 
mental  faculties  more ;  and  this  is  true,  for  while  it  is 
disturbance  only  in  such  cases  during  certain  stages  of 
the  convulsive  period,  there  is  total  abolition  of  all  the 
mental  faculties  in  the  severer  forms  at  the  same  stage. 

In  petit  mal  attacks  we  may  be  prepared  to 
note:  i.  The  mild  degree  of  muscular  disturbance  or 
commotion,  as  compared  with  that  present  in  grand 
mal  attacks.     2.  The  slower  invasion  and  lesser  degree 


148  SEIZURE    TYPES. 

of  involvement  of  the  faculties  of  the  mind  and  the 
quicker  return  of  the  patient  to  his  normal  state  after 
the  fit  is  over. 

Case  I. — R.  E.,  a  robust,  well-developed  young  man 
of  twenty-five  years,  was  standing  idle  when  the 
attack  began,  the  first  thing  noticed  being  a  marked 
pallor  that  covered  the  entire  face.  Presently  a  num- 
ber of  large,  irregular,  dark  blotches  appeared,  most 
noticeable  about  the  sides  of  the  face  and  on  the  neck. 
These  blotches  soon  became  of  a  dark,  livid  color, 
but  were  not  raised  above  the  surface  of  the  skin. 

The  patient  stood  motionless  for  a  minute,  the 
pallor  and  the  blotches  all  the  while  growing  in  promi- 
nence. Then  he  suddenly  called  to  the  nurse  who 
stood  near,  and  before  the  nurse  could  reach  him, 
cried  out,  "Oh!  Oh!"  and  started  to  fall  somewhat 
to  the  left.  The  first  muscular  movements  noted 
were  in  the  eyes,  both  of  which  rolled  upward  and  the 
eyelids  twitched  convulsively.  Next  the  mouth  was 
drawn  to  the  left  in  clonic  movements,  repeated  six 
times.  The  movements  next  appeared  in  the  right 
hand  and  arm,  then  the  left  hand  and  arm,  then  the 
left  side  of  the  face,  after  which  both  lower  extremities 
were  involved  in  several  spasmodic  jerks.  There  was 
no  tonic  period,  all  the  contractions  being  clonic, 
except  the  first  in  the  left  side  of  the  face ;  the  twitching 
of  both  eyelids  continued  throughout.  Both  pupils 
were  dilated  during  the  entire  time,  and  were  unre- 
sponsive to  light.  Neither  hand  was  firmly  con- 
tracted, the  fingers  of  both  being  slightly  flexed. 

The  progress  of  invasion  was  slow  and  deliberate 
throughout.  There  was  no  flow  of  saliva;  no  injury 
to  the  tongue.  The  comatose  period  lasted  two  min- 
utes, when  the  patient  arose,  looked  about  in  a  dazed 
way,  and  appeared  to  be  apprehensive  of  danger,  as 
was  indicated  by  his  quick,  nervous  movements  and 
his  apparent  desire  to  leave  the  spot.  This  disturbed 
period  lasted  ten  minutes,  when  the  patient  suddenly 
grew  calm  and  docile  and  was  able  to  answer  questions 
in  ah  intelligent  manner,  though  not  with  his  usual 
readiness.  He  said  that  he  felt  an  attack  coming  by 
a  "queer  feeling"  in  his  stomach,  and  that  he  did  not 


CASES    OF    PETIT    MAL    CONVULSIONS.  149 

lie  down  because  he  had  often  felt  that  way  without 
having  an  attack. 

Temperature,  pulse,  and  respiration  were  normal 
after  the  attack,  and  there  was  no  involuntary  action 
of  any  bodily  functions. 

Case  II. — M.  V.  was  sitting  down  when  it  was  noted 
that  his  pupils  were  beginning  to  dilate.  Immediately 
his  head  began  to  turn  slowly  and  almost  imper- 
ceptibly to  the  left.  While  this  was  going  on,  the 
patient  got  up,  walked  once  about  the  room  in  a 
purposeless  way,  opened  a  door,  stepped  out  on  the 
veranda,  and  closed  the  door  after  him;  almost  imme- 
diately he  re-opened  it  and  entered  the  room,  and 
took  up  a  standing  position  near  the  nurse  employed 
in  his  care. 

In  the  meanwhile,  the  patient's  head  had  become 
turned  completely  to  the  left,  and  slight  convulsive 
twitchings  were  observed  in  his  face,  being  most 
marked  on  the  left  side.  Shortly  after  these  had  set 
in,  saliva  began  to  flow  from  the  mouth,  though  it 
was  not  frothy  and  there  was  no  blood  in  it.  All  this 
time  the  patient  had  been  fully  unconscious,  having 
been  so  since  the  beginning  of  the  attack,  all  his  first 
movements  about  the  room  and  out  to  the  veranda, 
and  his  return  having  been  made  without  his  knowl- 
edge. With  the  fading  of  the  convulsive  twitchings 
in  the  face,  the  head  started  to  regain  its  normal 
position,  and  the  first  indication  of  returning  conscious- 
ness was  when  the  patient  sought  the  toilet  room  and 
voided  his  urine.  On  being  asked  immediately  what 
the  trouble  was,  he  replied,  "I  guess  I  have  just  had 
a  little  spell." 

The  seizure  lasted  three  minutes  in  all,  and  the 
bulk  of  it  was  made  up  of  disturbed  or  lost  conscious- 
ness; there  were  only  the  slightest  convulsive  move- 
ments, confined;to  the  face,  while  the  tonic  period  was 
entirely  absent. 

The  localized  spasm  in  the  face  in  this  case  and  the 
absence  of  any  cry,  or  fall,  might  have  tended  to 
confuse  it  with  Jacksonian  epilepsy,  but  the  single 
fact  that  consciousness  was  completely  lost  in  the 
very  beginning  was  sufficient  to  distinguish  between 
the  two,  for  in  true  Jacksonian  fits  consciousness  is 


150  SEIZURE    TYPES. 

often  but  little  disturbed — sometimes  not  at  all ;  while 
convulsive  movements  always  precede  any  disturbance 
in  this  direction. 

Many  Jacksonian  epileptics  are  fully  capable  of 
witnessing  their  own  seizures,  getting  clear  enough 
impressions  to  remember  them,  so  that  they  can  fully 
describe  them  in  detail  after  the  attack  is  over. 

In  this  case  there  was  no  elevation  of  temperature, 
or  any  increase  in  the  pulse  or  respiration  after  the 
seizure  was  over. 

Case  III. — C.  K.  complained  of  feeling  "generally 
miserable,"  and  showed  great  irritability  of  temper; 
he  wandered  about  the  house  in  an  aimless  way, 
entirely  at  variance  with  his  usual  custom. 

Finally,  while  walking  across  the  floor  of  the  smok- 
ing-room, the  attack  came  on.  The  patient  staggered 
backward  about  ten  feet,  stumbled,  then  sat  on  the 
floor  as  if  some  one  had  forcibly  thrown  him  down 
in  that  position.  He  began  to  swing  both  arms  about 
his  head,  then  lowered  his  hands  to  the  floor,  using 
them  to  shift  himself  about,  as  though  he  were  de- 
prived of  the  use  of  his  legs  and  feet  and  depended 
on  his  hands  for  locomotion.  Next,  his  face  became 
deeply  congested,  then  cyanotic;  this  quickly  passed 
and  changed  into  intense  paleness.  Both  pupils  were 
widely  dilated.  The  left  side  of  the  mouth  and  the 
muscles  about  the  left  eye  were  mildly  convulsed,  the 
face  being  drawn  somewhat  to  the  left.  He  remained 
in  the  sitting  posture  and  was  unconscious  ten  minutes. 

Presently  he  arose  to  his  feet,  and  his  face  assumed 
a  look  of  the  most  abject  terror;  he  began  walking 
about  the  room,  mumbling  incoherently,  and  appa- 
rently trying  to  make  the  nurse  understand  something 
he  was  incapable  of  explaining  in  a  lucid  manner. 
This  confused  condition  lasted  for  half  an  hour  before 
his  normal  state  was  re-established. 

Case  IV.— A.  L.  S.  was  standing  quietly  when, 
without  warning  of  any  nature  whatever,  she  suddenly 
fell  on  both  knees;  her  face  grew  pale  at  once,  and 
both  eyes  were  set  and  "apparently  stared  at  some 
object  on' the  floor  immediately  in  front."  Evidences 
of  slight  muscular  twitchings  were  noted  about  the 
throat;   the  last  of  these  terminated  the  seizure,  and 


CASES    OF    PETIT    MAL    CONVULSIONS.  151 

the  patient  was  able  to  get  up  immediately  after  that. 
The  entire  attack  did  not  last  more  than  fifteen 
seconds. 

On  regaining  her  feet  she  walked  about  for  three 
minutes  in  a  confused,  automatic  way,  when  she 
passed  into  her  normal  condition,  and  complained  of 
a  feeling  of  great  exhaustion.  On  being  questioned 
as  to  what  she  remembered  just  prior  to  the  onset  of 
the  attack,  she  declared  the  last  thing  she  recollected 
was  "a  vision  of  a  score  of  repulsive  faces  all  coming 
straight  toward  her."  In  this  case  none  of  the  bodily 
functions  passed  from  under  control.  There  was  no 
aura  of  any  kind ;  no  cry,  and  no  biting  of  the  tongue ; 
while  the  temperature,  pulse,  and  respiration  remained 
normal. 

Cases  in  which  patients  are  attacked  in  this  way, 
i.  e.,  when  they  suddenly  sink  to  the  floor  through  the 
simultaneous  loss  of  power  in  both  legs,  are  rare,  and 
indicate  a  lesion  in  the  internal  capsule  of  a  nature 
to  impair  all  the  fibers  of  the  motor  tract.  The  prob- 
lem in  such  cases  is  the  mechanism  by  which  con- 
sciousness is  so  quickly  and  so  sharply  lost. 

Case  V. — C.  S.  was  engaged  in  making  a  bed  when 
she  suddenly  collapsed,  falling  quietly  in  a  "crushing 
down"  way  to  the  floor.  (This  manner  of  falling  is 
typical  of  this  form  of  epilepsy  and  differs  wholly  from 
the  fall  of  the  grand  mat  seizure.  It  is  more  like  a 
general  giving  way,  a  gradual  collapse,  than  the  sharp, 
accentuated  fall  that  occurs  when  all  the  muscles  are 
suddenly  caught  in  a  tight,  vise-like  grip;  the  shock 
of  the  contractions  being  great  enough  to  throw  the 
individual  with  extreme  violence  to  the  ground.)  As 
soon  as  she  touched  the  floor  both  eyes  were  observed 
to  roll  upward;  the  lids  were  wide  open,  and  the 
expression  was  set  and  staring ;  the  pupils  were  widely 
dilated.  The  first  muscular  twitchings  occurred  about 
the  eyes,  being  equally  well  marked  on  both  sides. 
Next  the  left  arm  became  slightly  convulsed,  and  at 
the  same  time  drawn  up  across  the  chest;  the  fingers 
and  thumbs  flexed  were  in  the  scoop  position.  The 
knees  and  elbows  were  flexed ;  the  legs  were  drawn  up 
part  way,  and  the  left  arm  was  more  bent  than  the 
right.     The  patient  remained  in  this  position  fifteen 


152  SEIZURE    TYPES. 

seconds,  when  she  raised  herself  to  a  semi-recumbent 
one  and  began  feeling  about  the  floor  as  though 
searching  for  something,  this  action  being  purely 
automatic. 

Then  began  a  distinct  smacking  of  the  lips,  the 
so-called  tasting  movements  that  are,  not  infrequently, 
an  accompaniment  of  the  active  part  of  the  epileptic 
state.  On  the  subsidence  of  this,  she  began  to  talk 
incoherently,  but  was  almost  immediatery  conscious 
of  her  surroundings.  The  entire  attack  had  lasted 
three  minutes,  and  it  was  characterized  by  the  absence 
of  any  cry,  any  injury  to  the  tongue,  any  distinct 
convulsive  movements,  tonic  or  clonic;  any  loss  of 
control  of  bodily  functions,  and,  finally,  it  was  not 
followed  by  any  period  of  stertor  or  comatose  sleep. 
There  was  in  it  simply  a  period  of  muscular  incapacity, 
combined  with  a  sharp  loss  of  mental  ability;  the 
former  lasting  less  than  a  minute  all  told,  the  latter 
for  fully  three  minutes,  thus  confirming  the  statement 
previously  made,  that  mental  disturbance  is  more 
often  a  characteristic  of  this  light  form  of  epilepsy, 
while  mental  abolition  is  more  often  the  concomitant 
of  the  severer  forms  of  the  disease. 


ILLUSTRATIVE  CASES  OF  PSYCHIC  EPILEPSY. 

The  clinical  manifestations  of  this  form  of  epilepsy  are 
not  nearly  so  complicated  as  those  of  the  forms  just 
discussed,  for  the  reason  that  they  have  to  do  with 
the  mental  activities  of  the  individual  only ;  never  in 
any  case  passing  over  and  involving  the  motor  side 
in  any  manner  or  degree.  It  is  this  fact  which  gives 
psychic  epilepsy  its  interest,  and,  in  the  absence  of  any 
knowledge  of  the  mechanism  by  which  the  conscious 
life  of  the  individual  is  suddenly  snuffed  out,  with- 
out even  the  appreciable  tremor  of  a  muscle  infinitesi- 
mal in  size,  and  of  the  manner  in  which  it  is  as  sud- 
denly and  as  completely  restored,  we  can  at  this  time 
only  marvel  as  at  something  we  do  not  understand. 

Epileptics  themselves  refer  to  such  attacks  as 
"weaknesses,"     "dizzy    spells,"     "blanks,"   "faints," 


CASES    OF    PSYCHIC    EPILEPSY.  153 

''absences,"  "darknesses,"  etc.,  applying  these  terms 
in  some  instances  to  the  lighter  attacks  of  petit  mat. 

Some  who  suffer  from  psychic  and  grand  mal  seizures 
at  the  same  time,  do  not  regard  the  former  as  epilepsy 
at  all,  feeling  that  all  the  concomitants  of  the  grand 
mal  fit  must  be  present  before  there  can  be  a  real 
attack. 

Irrespective  of  this,  psychic  epilepsy  is  a  distinct 
form  of  the  disease  which  at  present  is  but  little 
understood,  and  which,  because  of  the  unobtrusive- 
ness  of  its  character,  often  exists  for  years  before  it  is 
recognized. 

The  cases  reported  here  came  under  the  writer's 
personal  observation  and  are  typical  illustrations  of 
their  kind. 

Case  I. — C.  S.,  a  man  of  forty-nine  years,  had  been 
an  epileptic  of  the  syphilitic  type  since  the  age  of 
forty-seven,  his  attacks  as  a  rule  having  been  general 
and  of  great  severity,  though  he  was  accustomed  to 
occasional  attacks  of  a  psychic  nature  also.  At  one 
time  he  had  been  employed,  in  an  adjoining  room,  in 
puttng  pamphlets  into  envelopes  and  addressing  them 
from  a  printed  list,  afterward  going  through  bundles  of 
them  done  up  for  the  mail  to  see  that  they  were  all 
correct.  I  speak  of  this  to  show  how  this  habit  of 
precision,  was  carried  over  into  the  automatic  psychic 
state  that  followed. 

The  patient  was  engaged  in  tying  the  pamphlets 
into  bundles  when  he  suddenly  started  up  and  came 
hastily  into  the  room  I  was  in.  The  expression  of  his 
face,  which  was  white  and  tense,  indicated  that  he 
was  in  a  seizure.  Both  pupils  were  dilated,  the  eyes 
having  a  set,  staring  expression,  and  the  appearance  of 
looking  with  a  strained  gaze  into  space  without  seeing 
anything. 

I  was  going  over  some  papers  in  the  safe  at  the  time. 
He  came  and  quietly  looked  over  my  shoulder  for 
possibly  ten  seconds,  then  turned  and  entered  a  closet, 
where  he  picked  up  some  pamphlets,  counted  them, 
adjusted  them  in  an  orderly  bundle,  and  laid  them 


154  SEIZURE    TYPES. 

back  on  the  shelf.  He  had  been  getting  pamphlets 
from  this  closet  for  several  days,  counting  and  arrang- 
ing them  each  time  he  took  them  out,  just  as  he  did 
on  this  particular  occasion. 

I  took  him  by  the  sleeve  and  led  him  to  the  window. 
He  came  without  resistance,  but  with  a  puzzled  look 
on  his  face.  His  pupils  were  insensible  to  light  or 
shadow,  and  the  corneal  reflex  was  much  blunted,  as 
was  sensation  all  over  the  body.  He  recoiled  a  little 
when  stuck  with  a  pin,  provided  he  saw  the  act ;  other- 
wise he  hardly  seemed  to  fell  deep  penetration.  I 
showed  him  my  watch  and  asked  him  the  time,  having 
to  shout  quite  loudly  to  make  him  understand.  He 
promptly  answered,  "  Twenty-five  minutes  after  nine," 
which  was  correct. 

I  motioned  to  him  to  take  a  seat,  which  he  did  at 
my  desk,  when  he  adjusted  his  glasses  and  began  to 
go  over  some  papers  in  a  businesslike  way,  taking 
up  one  batch  of  them  after  another,  examining  each 
carefully,  and  putting  them  all  back  exactly  as  he  had 
found  them.  He  then  got  up,  and  in  walking  about 
the  room,  saw  the  telephone  wire  where  it  came  through 
the  floor,  took  hold  of  it,  and  gave  it  a  vigorous  pull. 
I  told  him  not  to  do  that,  shaking  my  head  at  the 
same  time.  He  said,  "Oh!  it  must  come  up;  it  must 
come  up"  ;  but  he  dropped  it  without  making  another 
effort. 

The  condition  of  automatism  lasted  fifteen  minutes, 
and  pulling  at  the  wire  was  the  only  foolish  thing  he 
did.  In  all  other  respects  he  was  calm,  obedient,  and 
orderly  in  every  way,  and  it  might  have  been  hard  for 
the  uninitiated  observer  to  believe  that  the  patient 
was  having  a  psychic  seizure. 

Suddenly  he  returned  to  consciousness,  glanced 
quickly  about  the  room,  seemed  confused  at  finding 
himself  there,  and  at  once  returned  to  his  work.  Half 
an  hour  later  he  declared  he  had  never  before  seen  my 
watch ;  that  he  had  absolutely  no  recollection  of  being 
in  my  office;  though  he  knew  he  had  passed  through 
an  attack  on  account  of  the  headache  that  followed. 

A  week  later  he  had  a  very  violent  grand  mal  attack, 
in  which  he  fell  to  the  ground  and  fractured  his  nose. 

Case  II. — A.  L.,  a  woman,  frequently  had  "weak- 


CASES    OF    PSYCHIC    EPILEPSY.  155 

nesses."  When  engaged  in  conversation,  she  would 
suddenly  hesitate  as  though  trying  to  find  the  word 
she  wanted,  and  a  slight  pallor  would  sweep  over  her 
face  at  the  same  time.  She  would  then  stop  talking, 
and  in  ten  or  twelve  seconds  would  take  up  the  con- 
versation just  where  it  had  been  left  off.  Usually  no 
ill  effects  followed,  not  even  a  headache. 

Case  III. — E.  S.,  a  woman  of  unusual  intelligence, 
was  sitting  at  a  table  writing  a  list  of  names.  I  hap- 
pened to  be  watching  her  at  the  time  and  noted  that 
she  suddenly  changed  color,  but  kept  on  with  her 
work.  After  she  had  written  the  same  name  and 
address  six  times,  she  regained  consciousness  and 
appeared  much  embarrassed  at  what  she  had  done, 
knowing  that  she  had  repeated  the  names  while  under 
the  influence  of  a  seizure. 

Case  IV. — P.  DeM.  while  paring  vegetables  would 
suddenly  let  the  knife  drop  from  his  hand  and  sit 
motionless  for  from  five  to  ten  seconds,  then  pick  up 
the  knife  and  go  on  with  his  work.  At  other  times, 
while  playing  cards,  for  instance,  he  would  suddenly 
assume  a  blank  expression,  take  out  his  watch,  study 
it  carefully,  call  out  the  correct  time  and  say  he  must 
be  about  his  work.  Suiting  his  actions  to  the  word 
he  would  go  to  a  closet  on  the  floor  above,  and  get 
his  broom  and  dust  cloth  and  begin  to  work  at  the 
cleaning  he  is  accustomed  to  do  regularly  each  morning, 
always  looking  at  his  watch  before  starting  it. 

On  one  occasion  he  began  cleaning  at  9  o'clock  at 
night,  keeping  at  it  half  an  hour  before  consciousness 
was  restored.  On  this  occasion  he  said  just  as  the 
attack  came  on,  "It's  7.30  and  I  must  get  to  work." 
The  time  actually  was  9  p.  m.,  7.30  being  the  hour  he 
was  accustomed  to  do  the  work  each  day. 

When  fully  in  the  attack,  the  nurse  spoke  to  him, 
shouting  quite  loudly  in  his  ear  to  make  him  under- 
stand, asking  him  what  time  it  was,  and  the  reply  he 
gave  was  correct;  he  had  absolutely  no  recollection 
afterward  of  having  been  asked  the  time  or  of  having 
given  it. 

In  the  "Journal  of  Nervous  and  Mental  Diseases," 
August,  1902,  the  author  reported  the  case  of  a  com- 


156  SEIZURE    TYPES. 

mercial  traveler  who  was  subject  to  periods  of  autom- 
atism, one  such  period  having  lasted  twenty-eight 
days.  During  this  time  the  man  traveled  quite  ex- 
tensively in  the  West;  visited  his  customers;  wrote 
orders ;  sent  telegrams ;  and  engaged  in  various  busi- 
ness transactions  that  he  afterward  had  no  recollec- 
tion of  whatever.  The  only  way  he  could  be  con- 
vinced that  he  had  done  all  these  things  was  through 
reference  to  copies  of  all  letters  and  orders  he  had 
written,  and  through  daily  entries  in  his  diary,  in 
which  he  had  noted  his  condition  with  exactness 
and  regularity,  using  a  certain  Greek  sign  to  designate 
his  epileptic  attacks,  as  he  did  not  want  others  to 
know  that  he  was  a  victim  of  the  disease. 

Xear  the  end  of  the  automatic  period,  he  had' two 
or  three  grand  mal  seizures  and  utterly  collapsed, 
necessitating  his  restraint  in  a  hospital. 

In  addition  to  these  purely  psychic  cases, .  which 
involve  no  motor  element  whatever,  which  do  not  even 
disturb  the  fine  adjustment  and  regularity  of  the 
muscles  used  in  writing,  there  are  other  cases,  per- 
haps a  little  more  numerous,  in  which  motility  is 
abolished  during  a  very  small  space  of  time.  These 
do  not  display  any  convulsive  movements  whatever, 
the  muscles  simply  becoming  momentarily  limp  and 
inactive,  regaining  their  power  of  contractility  coin- 
cident with  the  reestablishment  of  consciousness,  as 
the  following  cases  show : 

L.  DeR. ,  while  combing  her  hair,  suddenly  let  the 
comb  drop  to  the  floor,  both  arms  falling  quietly  to 
her  sides  in  a  natural  position.  She  stood  immovable 
in  this  position  for  a  few  seconds,  stooped  and  picked 
up  the  comb  and  went  on  with  its  use  as  before.  She 
made  no  outcry  or  movement  of  any  kind ;  there  was 
no  twitching  about  the  face;  no  turning  of  the  eyes; 
no  biting  the  tongue — nothing  but  the  sudden  relaxa- 
tion in  both  hands  and  the  mental  blank,  both  of 


CASES    OF    PSYCHIC    EPILEPSY.  157 

which  disappeared  as  suddenly  and  as  completely  as 
they  came,  leaving  nothing  to  indicate  that  a  seizure 
had  occurred. 

M.  P.,  while  sitting  at  the  table,  suddenly  dropped 
her  knife  and  fork,  letting  both  hands  fall  in  her  lap. 
She  leaned  back  in  her  chair,  with  her  eyes  closed, 
and  the  eyelids  tremulous  and  the  face  pale;  she  re- 
mained in  that  position  not  exceeding  seven  or  eight 
seconds,  and  suddenly  regained  control  of  herself  and 
began  the  meal  again.  In  this  case  the  disturbance 
of  normal  muscular  tonicity  was  a  little  more  general 
than  in  the  case  last  described,  though  there  was  an 
entire  absence  of  muscular  contractions  of  any  kind 
or  degree. 

In  addition  to  these  clinically  distinctive  cases  of 
psychic  epilepsy  in  which  motility  is  fully  preserved, 
and  others  in  which  motility  is  locally  lost  during  the 
unconscious  period,  there  is  another  grade  or  class  of 
psychic  attacks  that  might  properly  be  termed  the 
epileptic  dreamy  state.  In  this  state  there  is  not,  so 
far  as  it  is  possible  to  judge,  any  alteration  in  motility, 
but  an  alteration  in  consciousness  only,  the  faculties 
of  the  mind  not  being  lost,  only  disjointed,  dissociated, 
and  beyond  the  individual's  control. 

L.  Pierce  Clark  reports  a  case  of  this  kind  in  the 
"Medical  Record"  for  February  20,  1897;  the  case 
being  that  of  a  woman  who  had  a  feeling  of  constriction 
across  the  forehead  just  before  the  beginning  of  the 
attacks,  during  which  her  conception  of  the  arrange- 
ments of  the  room  in  which  she  happened  to  be,  and 
of  the  people  who  chanced  to  be  near  her  at  the  time, 
is  different  from  that  which  she  has  while  in  her  normal 
state.  She  is  able  to  converse  at  such  times,  but 
declares  that  she  is  not  entirely  conscious  of  what  she 
says,  and  is  apt  to  express  ideas  entirely  contrary  to 
those  she  really  entertains.  When  this  condition  has 
passed,   she  remembers  what  she  said  while  in  this 


158  SEIZURE    TYPES. 

partially  subconscious  state  and  endeavors  to  correct 
wrong  impressions  made  at  that  time.  She  also  suffers 
from  grand  mat  and  petit  mat  attacks,  though  the 
attacks  described  above  are  far  more  frequent  in  occur- 
rence than  the  rest. 

Clark  reports  another  case  in  which  the  patient  may 
be  in  an  attenuated  psychic  state  when  spoken  to, 
and  will  fail  to  answer,  but  when  the  attack  is  over 
she  is  certain  to  ask  you  to  repeat  your  question.  She 
declares  that  her  attacks  "come  and  go  like  waves." 
Still  another  patient  has  attacks  so  light  and  transi- 
tory that  he  fails  to  read  part  of  a  line  or  part  of  a 
sentence ;  suddenly  realizing  that  he  has  lost  the  sense 
of  the  subject,  going  back  to  find  the  missing  link 
which  is  all  new  to  him. 

In  every  way  these  slight  degenerate  phases  of  dis- 
turbed consciousness  are  of  the  greatest  interest,  for 
the  line  that  divides  them  from  the  normal  is  at  times 
perilously  indistinct,  and  I  have  no  doubt  but  that 
they  may  and  do  exist  for  years,  even  sometimes 
through  life,  without  detection ;  and  it  is  interesting 
to  speculate  as  to  whether  the  process  involved  in  the 
production  of  these  states  may  not  be  identical  with 
the  process  underlying  the  minute,  forced  memory 
accessions  that  many,  perhaps  most,  people  experience 
some  time  in  their  life.  By  accessions  to  memory  I 
mean  the  sudden  interjection  into  the  field  of  con- 
sciousness of  some  insignificant  act  or  thing  experienced 
by  the  individual  years  ago,  the  memory  of  which  had 
never  been  revived,  its  revival  eventually  being  what 
might  be  termed  a  psychologic  accident. 

ILLUSTRATIVE  CASES  OF  JACKSONIAN   EPILEPSY.* 
In  this  form  of  epilepsy  we  have  again  to  deal  with 
disorders   of  motility,   localized   always,    though   not 
necessarily  remaining  so  throughout  the  seizure,  the 

*See  "Partial  Epilepsy"  for  more  complete  description  of  Jacksonian 
epilepsy. 


CASES    OF   JACKSONIAN    EPILEPSY.  159 

feature  of  motility  differentiating  the  fit  on  a  very- 
distinct  basis  from  the  psychic  epilepsy  just  described. 

Case  I. — A.  J.  was  sitting  on  a  chair  when  she  com- 
plained of  a  "tingling"  sensation  in  the  left  arm, 
which  she  grasped  quickly  with  her  right  hand.  The 
fingers  of  the  affected  hand  were  flexed  on  the  palm, 
the  thumb  being  underneath,  and  the  hand  flexed  on 
the  forearm. 

While  the  patient  was  grasping  her  left  arm,  she 
was  spoken  to  by  the  nurse ;  she  looked  up  and  smiled, 
though  made  no  reply.  After  the  convulsion  had 
passed,  as  it  did  after  three  or  four  simple  shock-like 
jerks  confined  entirely  to  the  arm,  the  patient  was 
able  to  recall  and  describe  all  that  transpired  while  her 
arm  was  in  contraction. 

She  grasped  the  arm  with  the  idea  of  checking  the 
extension  of  the  seizure.  There  seems  to  be  ground 
for  believing  that  this  is  possible  in  some  instances. 
Tying  a  string  or  a  handkerchief  tightly  about  the 
upper  arm  when  the  attack  begins  in  the  fingers  some- 
times has  the  same  effect. 

Case  II. — C.  W.,  a  man  of  fifty  years,  a  subject  of 
brain  syphilis,  frequently  has  attacks  that  are  confined 
wholly  to  the  muscles  of  one  side  of  his  face.  During 
these,  if  the  contractions  are  not  too  powerful,  he  can 
talk  well  enough  to  be  fairly  well  understood.  At 
other  times  the  seizure  spreads  and  involves  one  arm. 
In  either  case,  after  the  fit  is  over  the  man  is  able  to 
describe  all  that  transpired  about  him  while  the  fit 
was  in  progress. 

Case  III. — J.  P.,  a  boy  of  eighteen  years,  was  subject 
to  both  grand  mal  and  Jacksonian  epilepsy ;  individual 
attack  which  began  as  the  latter,  extending  at  times 
into  the  former;  while  at  other  times  the  Jacksonian 
type  was  preserved  pure  throughout. 

As  he  was  starting  to  go  from  one  building  to  an- 
other, it  was  noticed  that  he  stopped  and  remained 
motionless  for  some  seconds,  when  the  right  arm 
began  to  be  violently  convulsed,  the  fingers  being 
sharply  flexed  on  the  palm,  the  thumb  held  down  by 
them.  The  nurse  approached  him,  thinking  he  might 
fall,  but  he  showed  no  indication  of  doing  so.     On 


l6o  SEIZURE    TYPES. 

being  asked  what  the  trouble  was,  he  replied,  "  I — 
am — having — -a — fit."  He  was  then  told  to  sit  down, 
but  answered,  "No, — I'll — be — all — right — in — a — few 
— minutes." 

The  disturbance  passed  completely  in  a  few  seconds 
and  he  was  himself  fully  at  once;  just,  indeed,  as  he 
had  been  throughout  the  seizure,  consciousness  being 
at  no  time  impaired,  much  less  lost.  The  contractions 
did  not  extend  further  than  the  upper  arm,  the  shoulder 
remaining  uninvolved.  His  face  was  natural  in  ex- 
pression and  his  pupils  normal  throughout. 

Three  or  four  years  prior  to  this  particular  fit, 
J.  P.  was  accustomed  to  having  a  series  of  from  270  to 
280  attacks  in  a  single  day.  Frequently  he  might  be 
noticed  dropping  on  one  or  both  knees  as  he  was 
walking  across  the  lawn,  remaining  in  that  position 
two  or  three  seconds,  regaining  his  feet,  only  to  go 
down  again  a  few  steps  further  along. 

In  other  cases  the  convulsive  movements  may  appear 
in  half  the  body,  beginning  in  the  hand  or  foot,  while 
again  they  may  be  confined  to  isolated  groups  of 
muscles,  especially  about  the  face,  the  par  cellar  epi- 
lepsy of  the  French. 

Jacksonian  epilepsy  is  generally  due  to  some  form 
of  focalized  lesion  in  the  cortex  of  the  brain. 

Jacobi  *  reports  the  case  of  a  girl  of  seven  years, 
who  began  to  have  twitchings  in  the  right  hand  four 
months  after  an  injury  to  her  head  on  the  left  side 
by  falling  from  a  swing.  A  few  months  later  she  had 
general  convulsions,  which  soon  ceased  and  were  fol- 
lowed by  more  profound  twitching  spasms  in  the  right 
hand.  At  times  she  had  "numbness  and  tiredness  in 
both  arms."  The  majority  of  her  attacks,  which  con- 
tinued to  occur  at  quite  frequent  intervals  for  five 
years,  were  Jacksonian.  Four  years  after  the  onset 
of  the  disease,  Dana  noted  her  mental  condition  as 
"particularly  bright  and  mature,"  adding,  "the 
attacks   were   quite   typical   examples   of  Jacksonian 

*  "Medical  Record,"  July  24,   1897. 


Plate  8. 


T.  P.  in  a  grand  mal  seizure,  during  which  consciousness  was  partially 
retained.  The  fit  is  more  marked  on  the  left  than  on  the  right  side,  as 
indicated  in  the  photograph  by  the  prominence  of  the  muscles  in  the  left 
arm,  where  the  contractions  are  tonic.  The  convulsion  in  the  left  leg  is 
clonic,  as  shown  by  the  blurred  outline  of  the  left  knee.  This  patient  is 
subject  to  classical  attacks  of  Jacksonian  epilepsy,  affecting  the  left  arm 
only.  He  is  able  to  carry  on  a  conversation  while  such  attacks  are  in 
progress. 


SERIAL    ATTACKS.  l6l 

epilepsy.  She  never  had  any  severe  headaches,  no 
vomiting,  no  optic  neuritis ;  the  cause  probably  lay  in 
some  slight  degenerative  changes  in  a  limited  area  of 
the  motor  cortex." 

The  case  was  reported  under  Jacksonian  Epilepsy; 
Adenoma  of  the  Liver;  Acute  Ascites  with  Tubercle 
Bacilli.  Death  was  due  to  the  latter  affection,  symp- 
toms of  which  had  appeared  some  months  previously. 
There  was  at  the  same  time  probably  no  connection 
between  the  various  pathologic  conditions  and  her 
epilepsy. 

It  is  important  to  remember  that  true  Jacksonian 
epilepsy  rarely  affects  the  intellect.  It  is  essentially 
a  disease  of  the  motor  apparatus,  and  from  a  clinical 
standpoint  it  is  the  simplest  of  recognition  of  all  the 
various  forms  of  epilepsy. 

SERIAL  ATTACKS. 

The  word  serial  in  this  connection  is  used  in  its 
literal  sense,  namely,  "placed  one  after  another;  con- 
tinued succession,"  since  the  convulsions  in  this  form 
of  epilepsy  follow  one  another  with  more  or  less  rapidity 
until  a  large  number  have  occurred — a  number  ranging 
anywhere  from  five  or  six  up  to  several  hundred, 
varying  greatly  in  different  cases  and  in  the  same  case 
at  different  times. 

Serial  attacks  stand  midway  between  isolated 
seizures  and  the  severest  form  of  epilepsy — status 
epilepticus ;  the  gradation  in  this  respect  being :  (a)  single 
attacks  which  may  occur  daily  or  more  often,  or  may 
be  months  apart,  and  which  are  not  usually  of  great 
moment,  so  far  as  the  patient's  life  is  concerned; 
(b)  serial  attacks  which  occur  hourly  or  oftener  for 
days  at  a  time,  and  which  are  more  dangerous  to  life 
than  those  that  occur  one  at  the  time ;  and  (c)  status 
epilepticus,  in  which  the  attacks  follow  one  another 
with  great  rapidity,   frequently  being  less   than  five 


1 62  SEIZURE    TYPES. 

minutes  apart,  until  hundreds  have  occurred.  The 
danger  to  life  when  status  develops  is  always  great. 

As  a  rule,  serial  attacks  most  often  occur  in  epileptics 
subject  to  grand  mal  seizures,  though  others,  espe- 
cially those  who  have  psychic  and  petit  mal  seizures, 
may  also  have  it. 

The  chief  clinical  difference  between  isolated  and 
serial  attacks  lies  in  the  point  of  frequency.  We  can 
easily  imagine  a  single  grand  mal  convulsion  divided 
into  four,  eight,  or  twelve  parts,  each  part  representing 
a  serial  convulsion.  As  a  rule,  single  serial  attacks 
are  not  so  severe  as  single  attacks  complete  in  them- 
selves. 

To  carry  the  illustration  a  little  further,  we  may  say 
that  serial  epilepsy  is  a  composite  form  of  the  disease, 
made  up  of  many  similar  attacks  due  in  all  probability 
to  the  same  cause,  the  convulsions  showing  themselves 
in  the  nature  of  repeated,  sudden  liberations  of  energy 
instead  of  a  single  grand  discharge.  It  is  characteristic 
of  many  cases  to  have  three  or  four  or  more  convulsions 
at  somewhat  fixed  intervals,  this  being  especially  true 
of  the  epilepsies  that  group  themselves  about  the  men- 
strual period. 

Some  male  epileptics  seem  to  show  a  tendency  to 
have  more  attacks  at  one  time  than  at  another,  without 
any  apparent  cause,  having  a  number  when  they  do 
appear  and  remaining  free  from  further  manifestations 
for  some  time  afterward,  when  the  series  will  be  re- 
peated. This  is  one  form  of  serial  epilepsy,  and  it  is 
milder  in  character  than  the  serial  attacks  that  come 
on  at  any  time  wholly  irrespective  of  any  periodicity 
and  often  lasting  until  hundreds  have  occurred. 

Serial  attacks  of  the  latter  and  graver  kind  do  not 
seem  to  show  any  fixed  tendency  to  recur,  differing  in 
this  way  from  those  lighter  in  form. 

In  rare  cases  the  temperature  in  serial  epilepsy  may 
reach  1050  F.  or  over,  but,  as  a  rule,  it  rarely  goes 


Plate 


A  good  illustration  of  a  motor  epileptic.  This  patient  had  nearly  6000 
epileptic  seizures  in  seven  years,  the  type  of  his  disease  being  such  that 
he  suffered  but  little,  if  any,  mental  impairment  at  the  end  of  that  time 
as  the  result  of  such  attacks.  Conjunctival  hemorrhage  following  a  fit — 
right  eye. 


SERIAL    ATTACKS. 


163 


above  1010  F.  or  1020  F.  The  chief  distinguishing 
point  between  it  and  the  far  more  fatal  condition  of 
status  epilepticus  is  unconsciousness,  or  epileptic  coma, 
which  is  always  present  sooner  or  later  in  the  latter, 
but  never  in  the  former.  The  moment  this  condition 
appears,  we  can  set  the  case  down  as  status,  provided 
the  temperature  is  high,  and  the  respiration  and  pulse 
frequent. 

The  following  five  cases  of  serial  epilepsy  show  the 
duration  and  type  of  the  attack,  the  highest  tem- 
perature recorded,  the  total  number  of  attacks,  and 
the  ultimate  result,  all  the  patients  having  recovered: 


No. 

Name. 

Duration  of 
Attacks. 

Type  of 
Attacks. 

Highest 

Temperature 

Recorded. 

Total 

Number  of 

Attacks. 

Result. 

I 

c.  s. 

96  hours. 

G.  M. 

105! 

140 

Recovered. 

2 

O.  T. 

24       " 

G.  M. 

IOO 

II 

it 

3 

J.  K. 

120       " 

G.  M. 

IOI 

120 

it 

4 

T.  D. 

120       " 

G.  M. 

IOI 

40 

a 

5 

J.  P. 

144       " 

G.  M. 

ioof 

220 

tt 

ILLUSTRATIVE  CASES  OF  SERIAL  ATTACKS. 

Case  I. — H.  C,  a  man  aged  twenty-two,  white,  and 
single;  had  been  epileptic  since  the  sixth  month; 
epilepsy  was  due  to  a  cerebral  palsy  occurring  at  that 
age ;  mental  condition,  imbecile ;  he  was  unable  to  give 
any  account  of  himself,  nor  could  a  satisfactory  history 
be  obtained  from  any  other  source. 

Attacks,  all  of  the  grand  mat  type,  occurred  three  or 
four  times  a  week.  His  mental  condition  was  worse 
after  an  attack  than  before;  he  became  extremely 
irritable,  violent,  and  had  threatened  suicide.  When 
the  attacks  subsided  for  a  few  days,  he  became  quite 
cheerful  and  good-natured,  and  engaged  in  some  light 
employment. 

On  June  7,  1902,  he  had  a  severe  grand  mal  attack 
at  5  p.  m.,  followed  by  subsequent  attacks  as  follows: 
5.30  p.  m.,  6.25,  6.40,  7,  7.25,  8.15,  8.40,  8.45,  8.50, 
9.15,  when  they  disappeared,  to  be  followed  by  one  of 
unusual  severity  at  one  o'clock  the  following  morning 


164  SEIZURE    TYPES. 

and  others  at  8.30  a.  m.,  at  3.20,  4.50,  and  11. 15  p.  m., 
two  occurring  after  that  before  five  the  following 
morning. 

His  temperature  after  the  first  attack  was  ioo°  F., 
pulse  no,  respiration  16,  while  after  the  tenth  attack, 
which  occurred  within  four  hours  of  the  first,  the  tem- 
perature had  gone  up  to  101.50  F.,  the  pulse  to  118, 
respiration  to  20.  The  severest  attack  of  the  series 
occurred  eight  hours  after  the  first,  and  ran  the  tem- 
perature up  to  10 20  F.,  and  the  pulse  to  128,  after 
which  improvement  began,  with  a  decline  in  all  symp- 
toms.    The  patient  was  not  unconscious  at  any  time. 

Case  II. — C.  H.,  a  man  aged  twenty-three,  white, 
and  single;  had  been  epileptic  since  the  fourteenth 
year;  epilepsy  was  due  to  trauma,  the  patient  having 
been  struck  on  the  head  by  a  limb  falling  from  a  tree, 
and  causing  a  fracture  of  the  frontal  bone  of  the  skull. 
Mental  processes  were  slow  and  dull;  the  mental 
stupor  was  of  a  kind  to  indicate  probability  of  im- 
provement under  proper  treatment  long  enough 
continued.  The  attacks  at  first  were  all  of  the  petit 
mal  type,  but  changed  later  to  include  grand  mal 
also. 

He  began  to  have  a  series  of  attacks  at  9.10  a.  m. 
on  July  29,  1902,  the  attacks  occurring  thereafter 
in  the  following  order:  9.10,  9.13,  9.22,  9.25,  9.30, 
9.35,  9.45,  9-52,  9.55,  after  which  they  were  checked, 
to  recur  a  few  hours  later  as  follows:  1.30,  2,  2.30,  3, 
3.40,  3.45,  4,  4.15,  4.20,  4.25,  4.35,  4.45  a.  m.  ;  again 
stopping  until  8.30  the  same  morning,  after  which 
they  appeared  at  8.30,  9.30,  n,  12.30,  12.55,  I-S°> 
2.05,  2.40,  and  9  p.  m.,  the  last  being  very  mild. 

The  patient  had  thirty  attacks  in  the  series,  all 
told.  Immediately  after  the  first  convulsion,  which 
was  extremely  severe,  the  temperature  was  1010  F., 
pulse  140,  respiration  30.  Three  hours  later  the  tem- 
perature had  reached  the  highest,  101.60  F.,  the  pulse 
and  temperature  gradually  subsiding  after  the  first 
fit,  all  being  normal  after  the  last  one. 

It  will  be  of  value  to  bear  in  mind  the  behavior  of 
the  pulse,  respiration,  and  temperature  in  these  cases 
that  we  might  compare  them  with  their  behavior  under 
status  epilepticus. 


REFLEX    EPILEPSY.  165 

REFLEX  EPILEPSY. 

A  very  considerable  difference  of  opinion  exists  as 
to  the  propriety  of  designating  any  type  of  epileptic 
convulsion  as  reflex.  On  the  other  hand,  many  dis- 
tinguished writers,  including  Gowers,  F6re,  Noth- 
nagel,  Voisin,  and  others  refer  to  the  reflex  causes  of 
epilepsy,  Gowers  dealing  with  it  in  this  way : 

"Irritation  of  peripheral  nerves,  visceral  or  ex- 
ternal, is  occasionally  the  exciting  cause  of  convul- 
sions which  may  continue  as  persistent  epilepsy. 
Irritation  of  the  gastrointestinal  nerves  oftener  pro- 
duces this  effect  than  irritation  of  the  nerves  of  the 
cerebrospinal  system." 

Gowers  mentions  the  case  of  a  man  whose  forearm 
was  painfully  bruised  in  an  accident,  and  who  had  a 
convulsive  attack  a  few  days  later,  which  began  in 
the  injured  limb,  with  pain  similar  to  that  felt  at  the 
time  of  the  injury.  It  developed  later  that  the  man 
suffered  from  cerebral  syphilis,  and  that  the  injury 
to  the  arm  was  only  the  exciting  cause  of  the  convul- 
sion. 

A  boy  of  fifteen  years,  mentioned  by  the  same 
author,  got  a  fragment  of  steel  imbedded  in  the  right 
cornea,  causing  great  pain.  A  comrade  tried  to  ex- 
tract it  with  a  piece  of  wood.  As  soon  as  the  wood 
touched  the  eye,  "the  patient  felt  a  peculiar  thrill, 
the  right  orbicularis  began  to  twitch,  the  head  turned 
to  the  left,  and  the  right  limbs  became  convulsed; 
other  fits  followed  during  nine  years." 

A  girl  of  nine  years,  who  came  under  the  writer's 
notice,  suffered  from  a  stricture  of  the  urethra,  which 
gave  rise  to  great  pain  during  micturition,  sometimes 
attended  with  reflex  convulsions.  These  disappeared 
entirely  after  the  stricture  was  cut. 

F.  J.  Campbell*  reports  the  case  of  a  boy  who  had 

*  "  American  Medicine,"  March  14,  1903. 


l66  SEIZURE    TYPES. 

convulsions  for  several  years  prior  to  his  thirteenth 
year,  the  attacks  being  infrequent  at  first,  but  occur- 
ring later  several  times  a  day,  all  of  the  grand  mal 
type.  He  had  a  marked  phimosis,  balanitis,  and 
irritating  smegma,  the  relief  of  which  checked  all 
further  convulsions  save  one  that  appeared  the  day 
after  the  operation. 

I  recall  a  man  of  forty  years,  a  mechanic  of  robust 
constitution,  unemotional  and  even-tempered,  and 
free  from  all  pernicious  habits,  save  that  he  was  a 
moderate  drinker,  who  could  be  thrown  into  a  severe 
general  convulsion  by  pressing  with  the  finger-tip  a 
small 'spot,  about  the  size  of  a  quarter  of  a  dollar, 
near  the  spinal  cord  in  the  lumbar  region.  The  first 
movement  of  the  patient  would  be  a  sharp  bending 
backward,  when  he  would  fall  to  the  floor  in  an  opis- 
thotonic  condition,  and  immediately  go  into  a  general 
convulsion. 

A  young  girl  of  fifteen  years,  whose  convulsions 
appeared  at  thirteen  and  who  not  infrequently  had 
200  or  more  in  a  month,  had  an  area  on  the  anterior 
surface  of  the  right  arm  about  four  inches  long  and  two 
wide,  the  spraying  of  which  with  ether  would  cause  a 
general  convulsion.  At  first  she  had  only  three  or 
four  attacks  in  twenty-four  hours,  but  later  on  they 
came  as  frequently  as  fifteen  or  twenty-five  in  the  same 
time,  alternating  between  grand  mal  and  petit  mal. 
She  was  well  developed,  muscular,  and  showed  no 
stigmata  of  genuine  epilepsy,  nor  were  her  attacks 
characteristic  of  the  true  disease. 

Fere  claims  that  "errors  of  refraction,  necessitating 
as  they  do  efforts  at  accommodation,  may  cause  epi- 
lepsy," and  says  that  it  has  also  been  ascribed  to  lesions 
of  the  respiratory  apparatus,  traumatisms  of  the  larynx, 
and  pulmonary  affection,  especially  those  of  the  pleura. 

Nothnagel  *  evidently  refers  to  the  same  form  of  the 

*  "Cyclopedia  of  the  Practice  of  Medicine,"  Ziemssen,  p.  257,  Vol.  xrv. 


Plate  10. 


L.  B.,  an  idiopathic  epileptic,  subject  to  both  partial  and  general  seizures 
which  are  preceded  by  an  aura  in  the  right  arm.  Irritation  of  the  "epi- 
leptogenic zone"  on  the  right  arm,  as  outlined  in  the  illustration,  will  induce 
an  attack.  In  many  partial  and  in  some  grand  mal  seizures  consciousness 
is  retained  (Clark). 


REFLEX    EPILEPSY.  167 

disease  in  what  he  has  to  say  concerning  "secondary 
epilepsy,"  holding  this  to  mean  that  form  in  which 
"peripheral  irritation,  or  central  anatomical  lesions 
serve  as  the  starting-point  for  the  development  of 
the  disease." 

As  a  rule,  the  epilepsies  due  to  such  causes,  i.  e., 
causes  which  do  not  lie  inherently  within  the  structure 
of  the  brain  cells,  so  far  as  we  can  determine  at  this 
time,  have  long  prodromal  periods,  during  which  the 
manifestations  are  confined  to  the  area  from  which 
the  irritation  springs,  and  which  may  be  either  sen- 
sory, motor,  or  vasomotor. 

Cicatrices  sometimes  mark  the  point  of  develop- 
ment of  the  aura.  Nothnagel  says :  "If  there  happens 
to  be  a  cicatrix  on  the  body,  one  may  sometimes, 
though  not  always,  produce  a  seizure  by  pressing  upon 
it." 

Ogles  reported  a  case  in  which  there  was  an  ex- 
tensive portion  of  the  body,  the  upper  extremity, 
upon  the  touching  of  which  a  seizure  could  be  pro- 
duced. 

Great  care  should  be  exercised  in  such  cases  as  this, 
as  well  as  in  the  one  we  mentioned  just  now,  in  which 
the  girl  had  an  epileptogenous  area  on  the  upper  right 
arm,  not  to  confound  them  with  hysteria.  These 
cases  bear  a  close  analogy  to  the  experiments  made 
by  Brown-Sequard,  who  was  able  to  throw  guinea- 
pigs  into  general  convulsions  by  irritating  spots  on  the 
face  from  which  the  skin  had  been  removed. 

When  convulsions  appear  as  the  result  of  some 
circumscribed  lesion  in  the  brain,  the  prodromal 
period  is  much  shorter  and  often  entirely  lacking,  the 
attack  setting  in  at  once  with  a  tonic  or  clonic  spasm 
in  a  particular  group  of  muscles,  or  even  in  a  single 
muscle,  as  in  the  region  supplied  by  the  facial  nerve 
or  one  of  its  branches. 

Again,  only  the  orbicularis  palpebrarum,  the  region 


l68  SEIZURE    TYPES. 

supplied  by  the  spinal  accessory,  or  certain  fingers 
may  be  involved.  In  these  cases  sensory  accompani- 
ments are  almost  wholly  lacking,  differing  quite 
radically  in  this  respect  from  the  epilepsies  due  to 
peripheral  irritations. 

It  would  be  interesting  to  pursue  the  study  of  the 
reflex  causes  of  convulsions  further,  but  enough  has 
been  said  to  show  in  a  general  way  the  type  of  causes 
that  lead  to  such  convulsions. 

The  essential  point  in  it  all  is  that  the  convulsions 
due  to  extrinsic  causes — causes  that  originally  lie  outside 
of  the  structural  composition  of  the  cells  of  the  brain — 
do  not  at  first  produce  genuine  or  essential  epilepsy, 
and  even  though  I  refer  to  them  as  reflex  epilepsy 
I  do  so  only  in  the  sense  that  the  convulsions  char- 
acteristic of  this  and  of  true  epilepsy  alike,  are  essen- 
tially one,  in  so  far  as  they  each  embrace  the  clinical 
manifestations  necessary  for  an  attack  of  motor 
epilepsy,  and  not  because  they  have  any  parallel  in 
etiology. 

It  may  also  be  said  of  most  convulsions  which  find 
the  cause  of  their  expression  primarily  and  essentially 
in  the  structural  composition  of  the  nerve  cells  in  the 
brain,  that  they  have  a  larger  motor  element  in  them 
than,  the  epilepsies  which  are  essentially  centric. 
So  clear,  indeed,  is  this  point  that  it  may  be  expressed 
in  this  way : 

Epilepsies  due  to  inherent,  cytologic  brain  deteri- 
oration or  defect  show  during  the  convulsion  a  mini- 
mum of  altered  motility  and  a  maximum  of  altered 
mental  state,  while  those  that  are  due  to  peripheral 
causes  show  a  minimum  of  altered  mental  state  and  a 
maximum  of  altered  motility.  For  this  reason  the 
motor  epilepsies  due  to  peripheral  irritation  may 
exist  during  a  patient's  life,  prolonged  to  the  average 
extent,  without  much  impairment  of  the  mind. 

Jacksonian  epilepsy  is  a  type  of  reflex  epilepsy  so  far 


EPILEPTIC    EQUIVALENTS.  169 

as  its  clinical  manifestations  go,  though  it  may  be 
due  to  other  causes.  It  is  noted,  however,  that 
Jacksonian  epilepsy  more  often  runs  into  or  is  already 
involved  with  severer  forms  of  the  disease  than  hap- 
pens in  the  case  of  reflex  convulsions. 

It  is  seldom  that  we  find  any  increase  in  the  tem- 
perature, pulse,  or  respiration  following  purely  reflex 
convulsions,  explainable,  in  part  at  least,  by  the  un- 
disturbed condition  of  the  thermic  centers  in  the  brain 
and  in  part  by  the  lessened  degree  of  muscular  involve- 
ment. 

If  it  were  practicable  and  desirable  to  make  a  grand 
division  between  the  epilepsies  due  to  extrinsic  causes 
that  act  at  first  in  a.  purely  reflex  manner,  and  the 
epilepsies  due  wholly  to  inherently  defective  conditions 
in  the  cells  of  the  brain,  it  would  simplify  the  study 
of  an  important  problem  to  a  very  great  extent.  We 
might  then  place  all  the  essential  epilepsies  in  one 
group,  the  unessential  in  another. 

EPILEPTIC  EQUIVALENTS. 

By  epileptic  equivalents  is  meant  something  that 
is  like,  that  is  equal  to,  or  that  in  some  degree  takes 
the  place  of  epilepsy,  thus  following  the  literal  meaning 
of  the  term  "equivalent,"  which  is:  "That  which  is 
regarded  as  equal  in  value,  force,  measure,  meaning, 
or  the  like,  to  something  else  used  in  comparison; 
something  that  will  offset,  counterbalance,  compen- 
sate, for  the  correlative  indicated. ' ' 

Epileptic  equivalents  may  be  referred  to  as  frag- 
ments of  epilepsy  complete  in  themselves,  since  such 
seizures  have  only  a  partial  resemblance  to  epilepsy 
in  its  complete  forms. 

Some  neurologists  question  the  existence  of  epileptic 
equivalents  as  independent  affections,  choosing  rather 
to  regard  these  vagrant  manifestations,  whether  they 
are  motor,   sensory,   psychic,   or  vasomotor  in  char- 


170  SEIZURE    TYPES. 

acter,  as  indications  of  epileptic  seizures  that,  for 
some  reason,  passed  unobserved. 

Tomlinson*  is  among  those  who  reject  the  psychic 
epileptic  equivalent,  which  up  to  this  time  has  been  the 
most  commonly  accepted  of  them  all,  holding  as  fol- 
lows: "I  do  not  believe  in  the  so-called  epileptic 
equivalent.  I  believe  these  states  are  not  the  equiv- 
alent of  the  convulsion,  but  they  are  conditions  of 
mental  aberration  following  the  disturbance  in  con- 
sciousness which  takes  place  as  the  result  of  an  attack 
of  petit  mat,  and  which  persists  as  mental  status." 

M.  Allen  Starr f  describes  the  condition  in  a  number 
of  cases,  referring  to  it  as  embracing  a  state  of  con- 
sciousness which  differs  not  only  from  normal  con- 
sciousness, but  from  the  state  of  unconsciousness  that 
usually  occurs  in.  epileptic  attacks,  these  intermediary 
states  being  termed  the  psychic  epileptic  equivalent. 

Starr  reports  several  cases  in  illustration,  and  adds 
that  "all  of  them  appear  to  have  'nervous  discharges' 
from  those  parts  of  the  cortex  whose  activity  is 
synchronous  with  the  mental  processes." 

As  previously  stated,  the  psychic  epileptic  equiva- 
lent is  the  most  common  of  all  the  equivalent  states, 
and  whether  we  admit  or  not  that  the  disturbance  in 
consciousness  follows  and  is  due  to  a  minor  attack  of 
epilepsy,  we  know  that  this  particular  equivalent 
assumes  two  very  different  phases,  appearing  in  one 
set  of  cases  in  the  form  of  a  sudden,  maniacal  outbreak 
of  the  greatest  violence  which  lasts  anywhere  from  a 
few  moments  to  several  days;  while  in  another  set 
of  cases  they  appear  in  the  form  of  quiet,  orderly, 
processes  of  altered  or  lost  consciousness,  during  which 
there  is  not  the  slightest  indication  of  any  motor  dis- 
turbance whatever. 

In  cases  that  come  under  the  former  head  we  can 

*  "Journal  of  the  American  Medical  Association,"  Jan.  17,  1903. 
t  "Familiar  Forms  of  Nervous  Diseases,"  1890,  p.  261. 


EPILEPTIC    EQUIVALENTS.  171 

safely  assume  that  the  discharging  lesion,  or  the  area 
in  which  inhibition  is  temporarily  set  aside,  is  general 
enough  to  involve  the  parts  of  the  cortex  that  preside 
over  all  the  forms  of  motion,  together  with  the  parts 
that  control  conscious,  intellectual  action. 

I  have  previously  described  numerous  cases  of 
psychic  epilepsy  in  which  the  mind  was  suddenly  and 
temporarily  lost,  the  body  being  in  nowise  disturbed 
in  any  of  its  parts  or  functions. 

Some  writers  class  attacks  like  these  as  psychic 
epileptic  equivalents,  a  practice  in  which  we  do  not 
agree.  It  seems  best,  so  long  as  psychic  epilepsy  is 
a  form  of  the  disease  complete  in  itself,  not  to  fix  on 
it  the  character  of  simply  being  "equal  to  or  like 
something  else." 

From  the  number  of  attacks  of  this  kind  which  I 
have  had  the  opportunity  of  studying  clinically  in 
detail,  I  can  say  with  quite  firm  assurance  that  they 
were  in  nowise  complicated  with  any  other  epileptic 
state  or  condition,  the  sudden  loss  of  consciousness 
appearing  in  all  in  a  sharp,  distinct,  clear-cut  manner, 
without  the  shadow  of  motor  disturbance  in  any  degree 
in  any  part  of  the  body.* 

When  we  come  to  the  second  form  of  the  so-called 
psychic  epileptic  equivalent,  that  in  which  there  is 
motor  disorder,  with  prolonged,  intense  violence,  we 
have  an  entirely  different  proposition,  for  here  such 
disturbance  often  follows  an  epileptic  seizure  of  some 
notable  kind. 

So  closely  interwoven  is  the  fit  itself  with  the  sub- 
conscious period  of  motor  violence  that  follows,  that 
the  patient  himself  cannot  distinguish  between  the  fit 
and  the  subsequent  state.  The  two  are  dovetailed  into 
such  close  apposition  that  the  line  of  demarcation  is 
destroyed  by  merging  as  much  into  one  side  as  in 

*  "The  Silent  Forms  of  Epilepsy,"  by  William  P.  Spratling,  "New 
York  Medical  Journal,"  Oct.  11,  1902. 


172  SEIZURE    TYPES. 

the  other.  Nor  is  it  possible  to  say  absolutely  whether 
mental  and  physical  violence  ever  occurs  indepen- 
dently of  a  forerunner  in  the  form  of  a  very  mild 
seizure ;  but  it  seems  reasonable  to  suppose  that  such 
may  be  the  case,  for  this  violent  state  is  closely  analo- 
gous and  often  identical  with  ordinary  outbursts  of 
mania  not  associated  with  epilepsy  in  any  form. 

Such  mental  disturbances  appear  as  strange,  violent 
impulses  of  short  duration.  The  patient  may  begin  to 
speak  suddenly  in  an  unusual  and  incoherent  way,  or 
exhibit  rude  behavior,  or  to  destroy  various  objects, 
while  others  in  this  state  seem  to  possess  superhuman 
strength  and  not  infrequently  wound  or  kill  those 
about  them.  Others  lose  all  sense  of  decency  and 
are  given  to  exposing  their  person  in  public  places. 
Lesague  has  shown  that  those  among  the  insane  who 
practise  indecent  exposure  are  often  epileptic,  a  fact 
the  author  had  ample  occasion  to  verify  in  his  care 
of  some  two  hundred  insane  epileptics  for  a  number 
of  years. 

These  unprovoked  assaults  and  indecencies  are 
usually  committed  while  the  individual  is  unconscious, 
and  he  knows  nothing  of  it  until  told  of  it  afterward, 
when  he  usually  falls  into  great  depression  or  has  a 
regular  convulsion  which  breaks  up  the  abnormal 
state. 

Such  cases  as  these  may  properly  be  called  psychic 
epileptic  equivalents,  for  they  are  manifestly  inter- 
changes for  fits  of  ordinary  character. 

More  frequently,  however,  the  equivalent  state  that 
follows  is  only  a  part  of  the  result  of  a  mild  seizure 
that  could  not  be  differentiated  in  point  of  time  from 
the  equivalent  itself. 

The  case  of  R.  F.  H.,  mentioned  on  p.  173,  very 
clearly,  illustrates  the  psychic  epileptic  equivalent 
state  when  that  state  is  dependent  on  seizures  of 
another  kind. 


EPILEPTIC    EQUIVALENTS.  173 

The  following  is  from  the  author's  report  *  of  this 
case:  "The  patient,  a  man  of  forty,  an  epileptic  for 
eighteen  years,  entered  the  Colony  early  in  December, 
1901. 

"  His  family  history  was  not  good,  while  the  patient 
himself  drank  and  smoked  to  excess  until  a  year  after 
his  epilepsy  developed,  at  the  age  of  twenty-one.  He 
is  a  man  of  intelligence  and  was  profitably  employed 
as  a  commercial  traveler. 

"It  has  been  his  habit  for  years  to  keep  a  diary, 
noting  therein  his  epileptic  seizures  with  a  certain 
Greek  sign,  to  conceal  the  identity  of  his  trouble  as 
far  as  possible. 

"He  left  Rochester,  N.  Y.,  September  26,  1901,  for 
a  prolonged  Western  trip,  and  his  diary  faithfully 
records  the  activities  of  each  day  up  to  December 
14th  following,  when  he  entered  the  Colony.  The 
notes  in  the  diary  are  in  detail,  giving  the  names  of 
the  places  visited;  the  railroads  he  traveled  over  to 
reach  them;  the  hours  of  arrival  and  departure;  the 
names  of  the  firms  called  on ;  the  result  of  these  calls ; 
together  with  frequent  notes  to  show  how  he  felt,  how 
many  letters  he  wrote,  and  many  other  things  of  a 
personal  nature.  We  will  omit  these  diary  notes  be- 
tween September  26th  and  November  15th,  and  give 
them  from  that  time  on  as  copied  from  his  diary  by 
the  patient  himself : 

Nov.  15.  Little  business  to-day.  Went  to  Kalama- 
zoo in  afternoon.  Wrote  two  letters.  Serious  epilep- 
tic collapse  on  the  street  this  morning ;  at  Elkhart. 

Nov.  16.  Saw  Kalamazoo  trade.  Slight  touch  of 
epilepsy  in  evening.     Wrote  three  letters. 

Nov.  17.  Sunday.  Spent  the  day  indoors,  writing 
and  figuring.  Wrote  three  letters.  Epileptic  attack, 
after  a  smoke  this  afternoon. 

*  "Journal  of  Nervous  and  Mental  Diseases,"  August,  1902:  "Epilepsy 
in  its  Relation  to  Crime,"  by  William  P.  Spratling. 


174  SEIZURE    TYPES. 

Nov.  1 8.  Visited  trade  in  Battle  Creek,  Marshall,  and 
Albion.     Wrote  three  letters. 

Nov.  19.  Did  the  Jackson  and  Hillsdale  trade  to- 
day. Not  much  business.  Had  attacks  of  epilepsy 
both  forenoon  and  afternoon. 

Nov.  20.  Visited  Angola  and  Auburn.  Slept  at 
Columbia  City.  Wrote  one  letter.  Had  epileptic 
attacks  both  forenoon  and  afternoon  to-day. 

Nov.  21.  Columbia  City  and  Fort  Wayne  both 
attended  to-day.  Toledo  by  night.  One  slight  epi- 
leptic attack  to-day.     Wrote  four  letters. 

Nov.  22.  Spent  the  day  in  Toledo.  Up  to  Detroit 
on  evening  train.  Received  my  long-looked-for 
"medicine  quantity"  letter  at  last.  Wrote  four 
letters. 

Nov.  23.  All  day  in  Detroit.  Did  little  business. 
Troubled  with  chills  and  fever.  Took  strong  dose  of 
quinine  at  bedtime,  also  some  whiskey. 

Nov.  24.  Spent  all  day  on  correspondence  and 
literature,  in  hotel.     Wrote  four  letters. 

Nov.  25.  My  diary  says:  total  epileptic  collapse. 

Nov.  26.  My  diary  says  I  was  at  Pontiac,  also 
Detroit,  but  further  than  this  I  know  nothing,  and 
have  no  recollection  whatever  regarding  the  day. 

Nov.  27.  My  diary  says  I  got  up  at  8.30  by  my 
watch,  i.  e.,  railroad  time.  Utterly  worn  out.  No 
memory  left.  Saw  a  doctor.  Am  to  be  sent  home 
to-night  on  M.  C.  R.  R.  No.  3  lower  berth  on  sleeper. 
Night  message  sent  to  my  home  doctor,  my  firm,  and 
my  landlord.      (I  remember  none  of  this.) 

Nov.  28.  My  diary  says:  Breakfast  on  train.  It  also 
records  $30.00  turned  over  to  my  employer.  (I  have 
no  personal  recollection  of  these  items.) 

Nov.  29,  30,  and  Dec.  1.  At  hospital.  (No  record 
or  recollection  of  this.) 

Dec.  2.  My  diary  says:  Up  and  dressed  after  dinner. 
My  employer  called.  I  am  weak  but  mentally  clear 
to-day.     No  recollection  hardly. 

Dec.  3.  My  diary  says:  Up  at  9  a.  m.  No  further 
record. 

Dec.  4.  My  diary  says:  "Up  at  9  a.  m.  Dressed 
fully.  (From  this  I  infer  that  I  only  used  my  diessing- 
gown  on  the  other  two  days.)     My  employer  called 


EPILEPTIC    EQUIVALENTS.  I  75 

with  the  Craig  Colony  papers,  which  the  doctor  signed 
later. 

Dec.  5.  Up  for  breakfast.  Back  to  bed.  Up  again 
10  a.  m.  Wrote  a  letter.  Had  an  epileptic  attack 
at  7  p.  m.  Chewed  a  thermometer  when  being  put 
in  my  mouth  to  take  temperature.  (I  have  a  sort  of 
hazy  recollection  of  this— spitting  out  cut  glass,  etc., 
but  nothing  definite.) 

Dec.  6.  Up  and  dressed  for  breakfast.  Paid  $1.25 
for  thermometer.  To-day's  visitors  were  W.  H.,  Mrs. 
H.,  and  Dr.  J.     Wrote  one  letter. 

Dec.  7.  Up  and  dressed  7.30  a.  m.  Got  shaved. 
Went  outside  and  over  home.  Saw  Mrs.  H.  Back  to 
hospital  for  dinner.     Van  called  8  p.m. 

Dec.  8.  Sunday.  Three  ladies,  one  man  called  on 
me  to-day. 

Dec.  9.  Depressed.  Wrote  two  letters.  No  further 
record  in  diary. 

Dec.  10.  Diary  says:  Epilepsy  between  4  and  5 
p.  m.  Chewing  severe.  Record  of  four  letters 
written.  (Beyond  these  facts  diary  does  not  throw 
any  light,  nor  does  memory  recall  the  day  at  all.) 

Dec.  11,  12  and  13.  Back  home  again.  (No  recol- 
lection of  these  three  days.)  Diary  records  two  letters 
received  and  one  written,  but  memory  fails  to  recall 
them.  And  these  were  vitally  important  days,  too, 
when  I  was  making  arrangements  for  my  sojourn  at 
Craig  Colony,  and  trying,  presumably,  to  straighten 
out  my  affairs  before  leaving.  I  discovered,  on  my 
return  for  a  week  in  February,  that  I  had  given  away 
a  number  of  personal  effects  to  friends,  and  my  failure 
to  recall  this  fact  caused  a  few  rather  embarrassing 
blunders.  For  instance:  I  calmly  arranged  to  have 
some  furniture  taken  up  to  the  Colony,  which  I  had 
previously  sold  to  my  landlord. 

Dec.  14.  My  employer  accompanies  me  to  Sonyea. 
Diary  makes  note  of  the  main  facts,  but  my  memory 
fails  to  respond  when  I  try  to  recall  them  now. 

Dec.  23.  From  the  14th  till  now — a  week — my 
diary  makes  note  of  letters  received  and  answered. 
Also  states  that  on  Tuesday,  December  17th,  I  was 
epileptic  all  day,  and  on  the  18th  there  is  also  the 
sign  of  epilepsy,  but  as  far  as  personal  recollection  goes, 


176  SEIZURE    TYPES. 

my  memory  is  nil.  I  have  a  sort  of  "  hazy,"  "  dream- 
like" recollection  of  matters  during  that  period,  when 
I  try  to  recall  it  by  going  to  my  correspondence  and 
such  like,  but  am  unable  to  fix  things  at  all  definitely. 
(I  have  carbon-manifold  copies  of  the  letters,  which 
show  them  to  be  perfectly  normal  and  sensible,  yet 
my  memory  fails  to  retain  the  incidents  referred  to  in 
said  letters.) 

From  December  23d  till  to-day — over  two  months — 
I  have  been  in  better  health  than  for  years  past,  and 
have  had  but  three  epileptic  attacks.  (None  of  them 
was  serious,  and  each  clearly  traceable  to  exciting  or 
depressing  primary  causes.) 

The  main  features  noticeable  in  this  somewhat  dis- 
jointed description  of  my  goings-on  from  September 
26th  till  to-day,  and  which  I  desire  to  emphasize,  is 
the  practical  loss  of  memory  from  November  15th  till 
December  23d.  While  my  diary  keeps  a  fair  record 
of  most  of  the  time,  and  my  mind  recalls  certain  days 
and  incidents  dimly,  I  really  seem  to  know  nothing 
as  to  my  existence  during  that  period,  and  might  as 
well  have  been  in  a  comatose  condition.  Though  my 
letters  and  comments  seem  perfectly  lucid  and  rational, 
I  have  no  recollection  of  most  of  the  incidents  there 
narrated. 

"It  appears  from  the  foregoing  that  he  suffered  a 
'serious  epileptic  collapse'  on  November  15th,  and 
had  other  isolated  attacks  daily  up  to  the  20th,  when 
they  ceased,  only  to  reappear  again  in  the  form  of 
'total  epileptic  collapse'  on  the  25th,  from  which  time 
until  December  23d,  a  period  of  twenty-eight  days, 
he  had  a  '  practical  loss  of  memory. ' 

' '  It  does  not  appear  that  unconsciousness  during 
these  twenty-eight  days  was  absolute  and  complete; 
for  the  patient  himself  says,  with  every  evidence  of 
honesty  and  sincerity  and  without  any  motive  for 
evasion,  that  while  his  mind  could  recall  '  certain  days 
and  incidents  dimly,'  he  really  seemed  to  'know 
nothing'  of  his  existence  during  that  period. 

"  One  of  the  most  remarkable  features  of  the  case 


EPILEPTIC    EQUIVALENTS.  I  77 

was  the  patient's  seeming  ability  to  write  down  certain 
incidents  and  impressions  acquired  while  he  was  in  a 
subconscious  state,  and  yet  have  no  knowledge  of  the 
fact  later,  only  knowing  that  he  had  done  so  by  seeing 
his  own  writing  on  the  pages  of  his  diary,  or  copies  of 
letters  he  has  kept." 

States  in  epilepsy  in  which  the  individual  acts 
without  volition — acts  in  a  purely  automatic  way — 
are  of  great  interest  to  the  medical  jurist  and  constitute 
one  of  the  gravest  medicolegal  problems  we  have  to 
encounter.  These  states  are  more  fully  dealt  with  in 
the  chapter  devoted  to  the  medicolegal  aspect  of  the 
disease. 

OTHER  EPILEPTIC  EQUIVALENT  STATES. 

In  addition  to  the  equivalent  states  described  above, 
others  occur  of  a  sensory,  sensorial,  or  motor  character, 
their  connection  with  epilepsy  being  demonstrated  by 
their  coexistence  in  the  same  person,  or  in  the  patient's 
family,  and  by  their  essentially  paroxysmal  nature. 
Some  of  these  may  be  regarded  as  limited  or  incom- 
plete seizures,  as,  for  instance,  those  that  partake  of 
the  nature  of  a  definite  aura  which  fails  to  lead  up 
to  a  full  convulsion. 

Among  the  visceral  epileptic  equivalents  may  be 
mentioned  angina  pectoris,  which  may  precede,  coin- 
cide with,  or  follow  a  regular  attack  of  epilepsy. 
According  to  Fere,  when  the  convulsive  seizure  begins 
in  such  cases  with  a  violent  pain  in  the  head,  extending 
to  the  neck  and  precordial  region,  it  is  impossible  to 
mistake  the  implication  of  angina  pectoris.  In  some 
cases  the  entire  attack  may  be  limited  to  this  painful 
aura. 

Paroxysmal  tachycardia  has  been  thought  to  have 
some  relationship  with  epilepsy,  but  the  fact  that 
patients  in  such  cases  are  usually  free  from  any  other 
evidences  of  an  epileptic  nature,  makes  the  assumption 


178  SEIZURE    TYPES. 

doubtful  at  least.  In  such  cases  convulsive  move- 
ments as  well  as  the  loss  or  disturbance  of  conscious- 
ness are  both  lacking,  without  one  or  the  other  of 
which  in  some  degree  epilepsy  in  any  form  cannot 
be  present. 

Fere  reported  a  case  in  which  he  asserted  unpro- 
voked laughter  to  be  an  equivalent  of  epilepsy.  In 
the  absence  of  any  of  the  distinctive  phenomena  that 
accompany  epilepsy,  we  should  here  again  hesitate  to 
accept  such  a  thing  as  an  epileptic  equivalent,  espe- 
cially when  we  recall  the  association  at  times  of  uncon- 
trollable laughter  with  hysteria. 

Bombarda  *  declares  that  certain  sleep  states,  such 
as  nightmare,  starting  in  sleep,  pavor  nocturnus,  or 
night  terrors,  erotic  dreams,  and  seminal  emissions, 
are  simply  equivalents  of  petit  mat  epilepsy. 

Hamilton  and  Zuccarelli  agree  with  Bombarda  in 
believing  nocturnal  pollution  to  be  a  true  attack,  but 
from  such  views  conservative  neurologists  very  prop- 
erly dissent. 

Among  other  forms  of  epileptic  equivalents  are 
asthmatic  affections,  especially  when  the  asthma  sud- 
denly attacks  persons  previously  in  good  health. 
Fere  is  authority  for  the  statement  that  the  ' '  existence 
of  asthma  with  psychic  disturbance,  hallucinations, 
terrors,  fear  of  death,  false  croup,  and  spasm  of  the 
glottis  are  also  included  among  the  convulsive  phe- 
nomena assumed  to  be  allied  to  the  epileptic  state." 

Some  writers  hold  the  symptomatic  analogy  between 
spasm  of  the  glottis  and  incomplete  epileptic  seizures 
to  be  very  great;  among  them  being  Rilliet  and  Bar- 
thez,  who  describe  the  condition  in  substance  as  fol- 
lows: "The  infant  is  seized  suddenly  with  an  attack 
of  convulsive  suffocation.  Respiration  is  suspended, 
the  face  dark  and  congested,  the  head  drawn  back- 
ward, the  mouth  wide  open.     The  child  is  restless  and 

*  "Journal  of  Nervous  and  Mental  Diseases,"  Vol.  xxvii,  p.  342. 


EPILEPTIC    EQUIVALENTS.  I  79 

carries  its  hand  to  its  neck  as  if  to  remove  the  obstacle 
to  respiration ;  then  after  a  few  seconds  of  this  dyspnea 
it  makes  several  short,  sharp  inspirations,  without 
intervening  expirations,  soon  followed  by  a  faint  and 
wailing  inspiration,  or  sometimes  by  a  convulsive, 
noisy,  and  jerky  expiration;  at  the  same  time  the 
extremities  stiffen,  the  thumb  is  carried  into  the  palm 
of  the  hand,  the  fingers  stretched  on  the  metacarpus. 
.  .  .  .  Involuntary  evacuations  take  place.  Most 
frequently  consciousness  is  preserved;  sometimes  it  is 
lost." 

J.  Lewis  Smith,*  Holt,t  Strumpell,J  and  others 
fully  describe  the  same  condition,  all  agreeing  that 
attacks  of  laryngismus  stridulus,  or  spasm  of  the 
glottis,  may  cause  convulsions  and  unconsciousness. 
J.  Lewis  Smith  refers  to  the  affection  as  "internal 
convulsions,"  ascribing  to  it  clonic  and  tonic  contrac- 
tions of  the  respiratory  muscles  most  frequently,  but 
occasionally  those  of  the  face  and  limbs  also  occur. 

Trousseau  says  internal  convulsions  consist  princi- 
pally in  a  spasm  of  the  diaphragm  and  of  the  muscles 
of  the  abdomen  and  chest;  but  it  appears  that  the 
muscles  pertaining  to  the  larynx  are  also  affected  at 
the  same  time  with  these. 

It  is  the  opinion  of  writers  generally  that  a  neurotic 
element  underlies  the  affection  in  most  cases. 

It  has  already  been  stated  that  epilepsy  is  sometimes 
caused  by  pertussis,  and  attention  is  called  to  the  fact 
that  the  seat  of  local  irritation,  the  convulsive  closing 
of  the  glottis,  is  similar  in  nature  and  produces  similar 
results.  I  do  not  for  a  moment  class  spasms  of  the 
glottis  with  true  epilepsy,  but  with  the  so-called  epi- 
leptic equivalent.  The  seat  of  the  irritation  in  such 
cases  is  problematical.     The  brain  may  be  affected  in 

*  "Diseases  of  Children,"  1896,  p.  634. 

t  "Diseases  of  Infancy  and  Childhood,"  1900,  p.  672. 

J  Strumpell,  "Textbook  of  Medicine,"  1892,  p.  142. 


l8o  SEIZURE    TYPES. 

a  reflex  manner  only.  The  pathology  of  the  condition 
is  in  obscurity  at  this  time. 

It  is  unreasonable  to  suppose  that  true  epilepsy 
often,  if  ever,  follows  this  form  of  so-called  epileptic 
equivalent.  If  it  did,  epilepsy  would  be  vastly  more 
frequent  than  it  is  now-  Personally,  I  fail  to  recall  a 
single  instance  in  which  this  was  the  case. 

Among  the  prominent  sensory  equivalents  may  be 
mentioned  the  gastralgias,  enter algias,  nausea,  and 
vomiting  when  they  suddenly  occur  in  persons  known 
to  be  free  from  diseases  of  the  gastrointestinal  system, 
some  of  which  doubtless  constitute  incomplete  forms 
of  gastric  aurse,  while  certain  hunger  states,  to  be  dis- 
tinguished from  simple  bulimia — or  desire  for  food — ■ 
have  been  associated  with  epilepsy. 

Fere  *  has  reported  several  cases  of  the  hunger  evil 
in  which  the  abnormal  hunger  state  appeared  both  as 
an  aura  in  classic  attacks  of  epilepsy  and  as  an  equiva- 
lent in  others. 

The  migraines  also  belong  to  this  group.  The  rela- 
tionship between  these  affections  and  epilepsy  has 
long  been  in  dispute.  I  believe  it  is  associated  with 
the  disease,  especially  in  women,  who  more  frequently 
show  a  periodicity  in  convulsive  phenomena  than  men. 
Unquestionably  some  of  the  lighter  forms  of  epilepsy 
pass  for  periodic  sick  headaches.  It  is  the  rule  for 
psychic  seizures  to  be  followed  by  an  intense,  pro- 
tracted pain  in  the  head,  that  may  persist  for  several 
days. 

Moreau  de  Tours  states  that  the  migraines  of  epilep- 
tics leave  behind  a  profound  stupor,  often  coming  on 
and  disappearing  with  the  suddenness  of  epileptic 
paroxysms.  In  other  cases  a  periodic  migraine  seems 
to  replace  a  periodic  epilepsy. 

Tissot,  Parriot,  and  Lieving  are  among  those  who 
admit  the  connection  between  migraine  and  epilepsy. 

♦  "Revue  de  medecine,"  July  10,  1899. 


PARTIAL    EPILEPSY.  l8l 

Before  we  can  understand  the  relationship  between 
periodic  migraine  and  some  of  the  lighter  epileptic 
states  or  equivalents,  we  must  have  a  thorough  under- 
standing of  the  scope,  character,  and  causes  of  such 
states  and  equivalents. 

PARTIAL  EPILEPSY. 

(Synonymous  with   Tacksonian  Epilepsy.) 

We  find  occasional  references  in  the  literature  to  the 
epilepsie  partielle  of  the  French  writers,  considerable 
distinction  being  given  it  both  by  Voisin  and  by  Fere. 

Descriptively  speaking,  partial  epilepsy  refers  to 
that  form  in  which  the  convulsions  are  limited  to 
half  of  the  body,  to  one  arm  or  leg,  or  to  a  single 
group  of  muscles,  the  latter,  as  previously  stated, 
being  termed  by  the  French  parcellar  epilepsy  {Epil- 
epsie parcellaire) .  It  was  first  described  by  Prichard 
in  1822,  being  next  referred  to  by  Bravaisin  1827  under 
hemiplegic  epilepsy,  and  later  still,  in  1831,  by  Elliott- 
son  under  partial  epilepsy. 

The  studies  and  descriptions  of  all  these  writers, 
however,  were  inconclusive  and  incomplete  as  com- 
pared with  those  made  by  Hughlings- Jackson,  begun 
in  1866,  and  which  were  of  especial  value  on  account  of 
the  work  of  this  distinguished  physician  in  studying 
the  malady  from  the  diagnostic  point  of  cerebral 
lesions. 

At  the  outset  we  must  guard  against  the  mistake 
of  confusing  the  incomplete  attacks  of  ordinary  epi- 
lepsy with  the  partial  forms  of  the  disease,  the  latter 
being  a  distinct  type  in  its  own  manifestations;  the 
former,  an  ordinary  attack  from  which  some  of  the 
important  symptoms  are  missing,  this  form  more 
nearly  resembling  the  epileptic  equivalent  already 
described. 

The  causes  of  partial  epilepsy  are  numerous  and 
may  be  general  in  some  degree,  or  purely  local,  com- 


152  SEIZURE    TYPES. 

prising,  under  general  causes,  meningitis,  acute  or 
chronic,  syphilitic  infection,  uremic  poisoning,  exag- 
gerated emotional  states,  alcoholic  excesses,  and 
trauma — especially  of  the  skull  with  injury  to  the 
brain,  cerebral  hemorrhage,  thrombus  or  embolism,  and 
extrinsic  causes  that  act  in  a  reflex  manner,  like 
injuries  to  peripheral  nerves,  old  cicatrices,  and  various 
forms  of  irritation  in  the  different  viscera. 

As  a  rule,  there  is  no  cry  in  an  attack  of  partial 
epilepsy,  while  consciousness  during  the  attack  is 
seldom  completely  lost,  the  patient  being  able  in  some 
instances  to  witness  his  own  seizure  and  even  to 
converse  while  it  is  present.  Nor  are  such  attacks 
usually  preceded  by  an  aura,  though  in  some  cases 
there  may  be  sensations  of  numbness,  tingling,  pain,  or 
coldness  in  the  extremities  or  in  certain  localities,  not 
differing  essentially  in  this  respect  from  the  aura 
which  precede  regular  epilepsy.  Almost  invariably  the 
spasm  begins  in  the  face  or  in  an  extremity  and  pro- 
gresses according  to  certain  fixed  rules  described  by 
Hughlings- Jackson . 

When  the  spasm  begins  in  the  face  it  most  fre- 
quently affects  the  eye,  or  the  mouth,  the  former 
moving  laterally  or  upward  at  an  angle,  with  twitching 
of  the  eyelids.  The  mouth  is  drawn  upward  and  to 
one  side,  the  spasm  radiating  to  the  rest  of  the  face 
on  the  affected  side,  affecting  the  muscles  of  the  nose, 
the  alae  nasi  especially,  causing  that  organ  to  draw 
up  in  a  way  that  produces  a  grinning  aspect — a  condi- 
tion to  which  Voisin  gives  the  name  "rabbit's  nose." 

At  times  the  teeth  are  gnashed  together.  The 
muscles  of  the  neck  are  next  involved,  the  head  turning 
to  the  side  to  which  the  mouth  and  eyes  deviate.  Any 
further  extension  Of  the  spasm  affects  the  superior 
portion  of  the  body,  then  the  inferior  portion  on  one 
side,  and  when  it  is  the  right,  there  is  apt  to  be  aphasia. 

Again,  the  spasm  may  begin  in  the  thumb  or  one 


PARTIAL    EPILEPSY.  1 83 

of  the  fingers,  or  two  or  three  of  them  may  be  simul- 
taneously involved ;  the  next  step  is  the  flexing  of  the 
fingers  in  the  palm,  over  the  thumbs,  as  a  rule.  Then 
it  spreads  to  the  forearm,  the  elbow,  and  the  upper 
arm,  stopping  short  in  some  cases  before  involving  the 
shoulder- joint ;  while  again  it  may  proceed,  involving 
this,  and  then  the  head,  finally  affecting  the  lower 
extremity,  making  the  involvement  of  half  of  the  body 
complete. 

When  it  starts  in  the  lower  extremity,  it  generally 
starts  in  the  great  toe,  which  is  extended  or  flexed 
convulsively,  then  travels  up  the  leg  to  the  trunk. 
In  movements  in  the  upper  extremity  extension  pre- 
dominates, while  in  those  of  the  lower  extremity, 
flexion  is  more  often  noted. 

We  may  note  a  tonic  phase  of  the  spasm  only  in 
any  of  the  parts  affected  described  above,  or  they  may 
be  followed  by  clonic  movements  also ;  the  loss  of  con- 
sciousness that  follows  the  latter  in  some  instances  is 
short  and  the  coma  of  brief  duration. 

No  matter  how  mild  the  attacks  in  either  degree 
may  be,  whether  they  are  tonic  only  or  are  clonic  also, 
certain  physical  results  are  nearly  always  noted  after- 
ward, consisting  of  partial  or  complete  temporary  loss 
of  power  in  the  parts  involved  in  the  spasm.  For 
instance,  the  face,  when  drawn  strongly  to  one  side 
during  the  spasm,  may  remain  in  an  unbalanced  posi- 
tion for  several  days,  the  length  of  time  depending 
upon  the  duration  and  intensity  of  the  original  dis- 
charging lesion  in  the  brain.  Series  of  attacks  are 
especially  apt  to  cause  local  exhaustion  paralysis,  the 
same  condition  resulting  when  the  leg,  or  arm,  or  any 
particular  group  of  muscles,  is  implicated  in  the  pri- 
mary spasm. 

Fixity  in  locality  is  a  characteristic  of  partial  epi- 
lepsy, its  symptoms,  as  a  rule,  being  repeated  with 
each  seizure,  in  this  respect,  in  exact  duplication  with 


184  SEIZURE    TYPES. 

wonderful  regularity,  though  the  degree  of  intensity 
may  at  times  vary  greatly. 

Partial  epilepsy  in  rare  instances  may  be  replaced 
by  general  tetanoid  shocks  that  are  attended  with 
general  excitement,  indicating  a  more  universal  in- 
volvement of  the  brain,  particularly  disturbance  in 
the  portions  that  underlie  the  psychic  life.  Some- 
times, too,  such  attacks  are  replaced  by  marked  general 
trembling  which  may  persist  for  a  day  or  so,  the  patient 
being  meanwhile  in  an  uneasy,  apprehensive  mental 
state. 

It  is  only  in  those  forms  of  motor  spasms  or  dis- 
turbances in  which  the  impairment  is  local  that  the 
mental  faculties  remain  unaltered. 

Charcot  described  two  special  forms  of  hemiplegic 
partial  epilepsy,  tonic  contractions  being  character- 
istic of  one,  the  other  having  vibratory  movements 
which  affected  the  contractured  limbs  during  the  tonic 
phase,  followed  by  regular  clonic  movements  later  on. 

Infantile  hemiplegic  epilepsy  sometimes  differs  from 
partial  epilepsy  in  that  the  hemiplegia  follows  a  series 
of  convulsions  early  in  infancy,  the  convulsions  ante- 
dating the  hemiplegic  state,  though  the  two  forms  are 
not  infrequently  present  in  the  same  individual. 

Fere  mentions  ophthalmic  migraine  as  constituting 
a  partial  sensory  epilepsy  that  begins  with  excitement, 
violent  pains,  scintillating  scotomata,  etc.,  the  pain 
radiating  over  the  side  of  the  cranium  corresponding 
to  the  affected  eye  and  being  accompanied  by  nausea 
and  vomiting.  As  a  rule,  visual  disturbances  manifest 
themselves  first  in  the  way  of  dimness  of  vision  or 
hemianopsia,  while  in  others  blindness  may  be  com- 
plete. 

Scintillating  scotomata  are  held  to  be  of  special 
importance,  generally  occupying  the  peripheral  portion 
of  the  field  of  vision  and  consisting  of  ' '  larger  or 
smaller  balls  of  fire,  perhaps  in  the  shape  of  a  toothed 


PARTIAL    EPILEPSY.  185 

wheel  of  red,  white,  or  phosphorescent  aspect,  and  in 
rapid  vibratory  motion,  or  rotating  around  its  center." 

The  patient  is  confused  at  first  by  these  extraor- 
dinary phenomena  and  cannot  give  a  clear  account 
of  them,  but  is  able  to  do  so  later.  That  they  are 
dependent  upon  centric  causes  is  shown  by  the  fact 
that  they  continue  present  when  the  eye  is  closed  or 
when  the  patient  is  in  complete  darkness. 

Occasionally  the  scotomata  consist  of  simple,  lumin- 
ous, zigzag  lines  and  figures  resembling  an  electric 
spark. 

Sir  Lauder  Brunton  *  discusses  at  length  the  pos- 
sible relationship  between  migraine  and  epilepsy, 
saying  in  part :  "  If  the  terminal  branches  of  the  tem- 
porosphenoidal  artery  become  contracted  like  a  bit  of 
piano  wire,  as  the  one  which  runs  up  my  forehead 
does  during  a  headache,  the  nutrition  for  the  center 
of  sight  in  the  brain  must  necessarily  be  impaired, 
and  if  the  spasm  should  extend  further  down  the  artery, 
the  centers  for  hearing,  taste,  and  smell  will  also 
suffer. 

I  think  it  probable  that  such  impairment  is  the  cause 
of  the  indistinct  vision  in  hemianopsia,  i.  e.,  blindness 
to  all  objects  on  one  side  of  the  body,  either  to  right 
or  left,  even  of  complete  blindness  and  of  zigzags  which 
occur  either  before  or  during  an  attack  of  migraine." 

This  distinguished  author  says,  moreover,  that, 
while  the  idea  to  some  may  be  far-fetched,  he  inclines 
to  believe  that  the  fairies  which  many  people  declare 
they  see  are  nothing  more  than  the  colored  zigzags  of 
migraine  modified  by  imagination,  and  in  some  cases 
occasioned  by  an  abnormal  condition  of  one  or  the 
other  eye. 

Hallucinations  of  sight  during  epileptic  attacks  in 
which  there  is  mental  disturbance  are  not  uncommon, 

*  "Hallucinations  and  Allied  Mental  Phenomena,"  "Journal  of  Mental 
Science,"  April,  1902,  p.  227. 


1 86  SEIZURE    TYPES. 

but,  in  my  experience,  such  ocular  manifestations 
as  those  described  by  Fere  and  alluded  to  by  Brunton, 
in  which  this  condition  is  the  only  indication  of  an 
attack  of  epilepsy,  are  exceedingly  rare,  while  the  very 
fact  that  visual  aura  are  so  common  before  ordinary 
attacks,  and  often  so  complicated  in  their  formation, 
constitutes  additional  reasons  for  the  existence  of 
partial  epileptic  attacks  that  find  the  eye  in  ophthal- 
mic migraine  the  center  of  disturbance. 

In  such  conditions  the  pupils  are  usually  contracted, 
while  in  ordinary  epilepsy  they  are  the  reverse. 

At  the  French  Congress  of  Alienists  and  Neurol- 
ogists at  Nancy,  August,  1896,  Raymond  and  Sougues 
reported  a  case  of  partial  epilepsy  in  a  man  fifty-four 
years  old,  of  three  years'  standing,  the  man  suffering 
from  acromegaly.  The  epileptic  attacks  were  typic- 
ally Jacksonian,  limited  to  the  right  arm  and  right 
side  of  the  face.  It  was  stated  that  the  hypertrophy 
of  the  pituitary  gland  present  in  acromegaly  constituted 
a  tumor  capable  of  exciting,  from  a  distance,  the  cor- 
tical psychomotor  centers. 

TETANOID  EPILEPSY. 

Attention  was  first  called  to  this  form  of  epilepsy 
by  Prichard*  in  1822,  and  it  is  believed  to  be  exceed- 
ingly rare,  a  fact  which  may  be  explained,  in  part  at 
least,  by  the  failure  of  students  of  epilepsy  to  give 
it  a  place  of  its  own  in  epileptic  literature. 

From  a  consideration  of  the  patho-physiologic 
changes  that  occur  in  the  brain  during  an  epileptic 
seizure,  it  is  difficult  to  understand  why  there  should 
be  two  distinct  forms  of  spasm  during  the  progress 
of  a  fit ;  why  the  tonic  contraction  alone  does  not 
suffice  for  the  complete  liberation  of  nervous  energy. 

Apparently  this  is  not  the  case,  for,  except  in 
the  rarest  instances,  we  meet  with  two  forms  of  motor 

*  "Diseases  of  the  Nervous  System,"  p.  108. 


TETANOID    EPILEPSY.  187 

disturbance,  tonic  and  clonic,  neither  of  them  being 
fixed  nor  invariable  in  degree,  both  differing  greatly 
in  different  cases,  and  even  in  the  same  case  at  dif- 
ferent seizures. 

In  the  sense  in  which  we  use  tetanoid  in  this  con- 
nection, it  is  practically  synonymous  with  tonic; 
tetanoid  epilepsy,  or  tetanoid  seizures  in  epilepsy, 
as  it  is  best  to  call  it,  consists  in  tetanic  or  tonic-like 
contractions  that  occur  wholly  independent  of  any 
clonic  movements  whatever.  Care  must  be  taken 
not  to  confound  such  seizures  with  tetanus  in  any  form, 
for  they  have  no  connection  in  any  sense  other  than 
that  conveyed  by  the  brief  disease-picture  we  look 
on  when  the  tetanic  state  is  present — momentarily 
so  in  epilepsy;   more  continuously  so  in  true  tetanus. 

Prichard  divided  tetanoid  epilepsy  into  two  forms, 
convulsive  and  tetanic,  speaking  of  the  latter  as 
follows:  "The  less  frequent  or  tetanic  form  is  dis- 
tinguished by  sudden  fits  of  coma,  or  loss  of  sense  and 
consciousness,  without  convulsions,  but  attended 
with  a  tonic  spasm  of  the  voluntary  muscles,  the  whole 
trunk  becoming  during  the  fit  rigid  and  inflexible." 

In  speaking  of  the  clonic  form — the  convulsive — he 
described  it  as  being  similar  in  some  respects  to  or- 
dinary epilepsy,  with  clonic  convulsions:  "The  patient 
is  suddenly  seized,  the  limbs  stretched  out,  the  whole 
trunk  extended,  and  fixed  in  rigid  spasm;  eyes  wide 
open  and  staring;  pupils  strongly  contracted;  the 
convulsive  and  tetanoid  forms  are  closely  allied,  and 
both  may  attack  the  patient  within  a  few  hours." 

Delasiauve,  Jones,  Grasset,  Gowers,  and  Fere  allude 
to  the  affection  in  some  way,  the  former  appearing 
to  think  that  tonic  and  clonic  epilepsy  cannot  occur 
as  independent  affections. 

Jones  speaks  of  "a  very  perilous  and  fortunately 
very  rare"  form  of  tonic  contraction  that  holds  the 
muscles  of  the  chest  in  a  state  of  rigidity  long  enough 


155  SEIZURE    TYPES. 

to  cause  death.  A  case  of  the  kind  came  under  my 
own  observation,  that  of  a  woman  of  thirty  years,  who 
was  subject  to  grand  mat  attacks,  but  she  had  never 
previously  been  known  to  have  a  convulsion  like  the 
one  about  to  be  mentioned. 

She  went  to  a  faucet  over  a  marble  basin  to  get  a 
drink  of  water  before  leaving  the  building,  with  an- 
other person.  After  she  had  been  gone  five  or  six 
minutes,  she  was  called,  but  did  not  respond,  and  a 
moment  later  was  found  standing  by  the  wash-basin 
with  hands  lying  flat  on  the  marble  surface,  her  feet 
a  little  apart,  the  head  drawn  well  forward  and  down, 
dead.  The  entire  muscular  system  was  as  rigid  as 
wood  and  remained  so  until  after  the  patient  was  laid 
on  the  floor.  The  face,  neck,  and  upper  part  of  the 
body  showed  the  usual  dark  discoloration  that  follows 
death  from  asphyxiation.  It  was  clearly  evident  that 
she  had  suffered  a  powerful  tetanic  convulsion  involv- 
ing the  whole  body,  fixing  in  a  vice-like  grip  the 
muscles  of  the  chest,  causing  death  by  the  forcible 
locking  up  of  the  respiratory  movements. 

When  the  body  became  limp,  it  did  so  without 
preliminary  tremors  or  twitching  of  any  kind,  the 
wood-like  hardness  of  the  muscles  almost  instantly 
melting  away. 

I  have  known  of  other  cases  in  which  death  oc- 
curred during  the  attack,  with  the  patient  in  a  different 
attitude,   and  was  due  probably  to  the  same  cause. 

Gowers,*  while  stating  that  most  attacks  of  epilepsy 
consist  of  both  tonic  and  clonic  spasms,  says  that  in 
some  attacks  one  or  the  other  of  these  may  be  missing ; 
tonic  spasms,  light  in  form,  being  the  commoner  of 
the  single  type  kind.  "A  patient  falls  unconscious, 
is  rigid  a  few  moments,  then  is  better.  Occasionally, 
more  severe  attacks  consist  of  only  tonic  spasms,  as 
is  the  case  of  a  boy  whose  fits  were  as  follows:     His 

*  "Epilepsy  and  Other  Convulsive  Diseases,"  1901,  p.  95. 


TETANOID    EPILEPSY.  189 

head  was  first  turned  to  the  right,  then  his  arms  became 
extended  and  rigid,  the  right  being  more  abducted 
from  the  body  than  the  left.  Both  elbow-joints  were 
fixed  and  his  fingers  were  flexed  in  the  interosseous 
position.  In  a  few  moments  the  spasms  ceased,  last- 
ing a  little  longer  in  the  hands  than  elsewhere.  There 
was  no  clonic  spasm." 

A  girl  of  seven,  of  delicate  physique,  an  adopted 
child  whose  ancestry  was  obscure,  was  entirely  well 
up  to  three  years  and  a  half.  She  appeared  ill  one 
day,  listless,  dull,  and  pale,  and  had  a  loss  of  appetite. 
All  of  these  symptoms  became  more  pronounced 
during  twenty-four  hours,  when  nausea  and  vomiting 
set  in,  followed  by  convulsions.  The  convulsive 
movements  consisted  of  a  stiffening  out,  the  entire 
bod}''  being  rigid  and  firm,  the  head  drawn  strongly 
back,  the  back  powerfully  arched  in  a  typical  opis- 
thotonic  position.  The  legs  and  arms  were  straight. 
After  the  spasm  had  lasted  from  thirty  to  forty 
seconds,  it  passed  away  almost  instantly,  and  at  once 
the  little  patient  was  in  possession  of  all  her  faculties, 
though  she  felt  physically  weak  for  some  hours  after- 
ward. A  month  later  a  similar  attack  occurred  that 
shaded  off  into  clonic  spasms,  and  during  the  following 
three  years  and  a  half  she  had  from  two  to  five  attacks 
a  week,  some  tonic  only,  some  clonic  during  the  latter 
stage. 

She  also  had  what  her  friends  called  "nodding 
spells."  While  at  play  she  would  suddenly  stop  and 
vigorously  nod  her  head,  the  chin  falling  on  the  chest. 
She  would  at  once  straighten  up,  seem  a  little  confused 
and  languid,  but  go  on  with  her  play.  When  this 
nodding  spasm  occurred  while  she  was  at  the  table, 
her  forehead  would  strike  the  table  with  great  force, 
at  times  breaking  the  plate  she  was  eating  from.  I 
saw  her  once  just  after  her  head  had  vigorously  struck 
a  dish  of  oatmeal  she  was  eating. 


190  SEIZURE    TYPES. 

After  two  or  three  seizures  had  occurred  in  a  day, 
as  occasionally  happened,  she  would  suffer  an  exhaus- 
tion paralysis  involving  the  tongue  and  lips.  She 
could  not  speak  without  great  difficulty  and  indistinct 
mumbling  of  words,  and  suffered  a  constant  drooling, 
the  lips  appearing  full,  tense  and  flaccid,  reminding 
one  of  the  thick,  expressionless  lips  so  often  seen  in 
idiocy  and  other  inferior  mental  states. 

L.  Pierce  Clark  *  reported  the  case  of  a  male,  twenty 
years  of  age,  of  good  muscular  physique,  save  for  a 
slight  paretic  condition  of  the  right  side  which  fol- 
lowed a  hemiplegia  at  the  fourth  or  fifth  year,  who  was 
subject  to  series  of  tetanic  spasms  which  were  occasion- 
ally followed  by  classic  attacks  of  grand  mal. 

During  the  tetanoid  seizures  all  muscles  were  in  a 
state  of  rigidity  from  twenty  to  thirty  seconds,  the 
back  being  well  arched  each  time.  The  patient 
could  be  lifted  bodily  from  the  floor  by  supports  under 
the  heels  and  head.  He  finally  had  a  series  of  such 
attacks  which  ended  in  status,  and  caused  his  death. 

The  nodding  spasms  referred  to  in  the  case  of  the 
girl  are  known  as  salutatory  spasms  or  spasmus  nutans, 
and  are  mainly  found  in  children. 

MYOCLONUS-EPILEPSY. 

Myoclonus-epilepsy  is  an  association  disease  of  a 
comparatively  rare  type.  It  is  characterized  by  par- 
oxysmal asynchronous,  bilateral,  lightning-like  con- 
tractions of  the  trunk  and  of  the  proximal  muscles 
of  the  extremities  with  varying  intervals  of  entire 
freedom  from  such  movements,  and  accompanied  by  a 
more  or  less  persistent  grand  mal  type  of  epilepsy. 

The  condition  was  first  carefully  described  by 
Unverricht  in  1891  under  the  title  of  Family  Myo- 
clonus.. In  about  a  fourth  of  the  cases  it  occurs  sporad- 
ically.    In  a  monographic  study  of  the  condition,  Clark 

*  "American  Journal  of  Insanity,"  Vol.  LV,  p.  583. 


MYOCLONUS-EPILEPSY.  191 

and  Prout*  report  57  cases  of  myoclonus-epilepsy, 
which  number  includes  four  of  their  own  from  the 
Craig  Colony.  Since  their  study,  several  additional 
cases  have  been  reported  by  Sepelli,  Lundborg,  and 
others.  One  is  led  to  infer,  however,  that  the  cases 
are  by  no  means  so  rare  as  unrecognized,  cases  being 
diagnosticated  as  choreic  epilepsy,  epilepsy  with 
multiple  tics,  or,  perhaps,  epilepsy  associated  with 
hysterical  tics. 

The  hereditary  factors  of  the  association  disease 
are  even  more  pronounced  than  those  of  true  idio- 
pathic epilepsy,  all  showing  an  intense  neuropathic 
stock.  The  immediate  excitant  of  the  disease  is 
the  minimum  of  importance.  Of  all  the  alleged  causes, 
some  form  of  mental  stress  takes  first  place,  but  this 
cause  is  often  absent. 

In  the  development  of  myoclonus-epilepsy,  which 
usually  occurs  in  early  adolescence,  epilepsy  develops 
first  in  about  half  of  the  cases;  in  a  third  the  two 
diseases  have  a  simultaneous  onset.  The  seizures  are 
usually  more  or  less  imperfect  grand  mal  in  type  and 
are  generally  preceded  by  increased  myoclonic  con- 
tractions. Commonly,  the  seizures  are  followed  by 
free  periods  of  contraction  for  hours  or  days.  The 
myoclonus  portion  of  the  association  disease  is  more 
frequently  atypical  than  the  epilepsy;  the  hands,  feet, 
and  face  are  often  affected,  and  the  paroxysmal  char- 
acter of  periodic  contractions  is  less  sharply  outlined. 
The  diaphragmatic  or  wood-chopper's  grunt  is  a  later 
addition  to  the  myoclonic  symptoms,  indicating  an 
involvement  of  this  muscle. 

The  diagnosis  of  typical  cases  is  easy.  Errors  are 
generally  due  to  laying  too  much  stress  on  single 
symptoms  of  the  disease.     The  lightning-like  contrac- 

*  "The  Nature  and  Pathology  of  Myoclonus-epilepsy,"  "American 
Journal  of  Insanity,"  Vol.  lix,  No.  2,  October,   1902. 


192  SEIZURE    TYPES. 

tions  of  the  trunk  and  the  proximal  muscles  of  the 
extremities,  which  are  asynchronous  yet  bilateral, 
and  which  are  not  possible  of  production  by  the  will, 
occurring  in  an  epileptic  should  enable  one  to  make 
the  diagnosis. 

The  prognosis  as  to  recover}'  is  bad.  Life  is  usually 
curtailed  more  than  in  simple  epilepsy.  Death  occurs 
commonly  before  the  climacteric  from  emaciation  and 
general  marasmus  or  status  myoclonus.  The  pathol- 
ogy of  the  affection  is  not  yet  definitely  determined. 
Autopsies  in  several  cases  have  failed  to  show  gross 
macroscopic  changes  sufficient  to  explain  the  con- 
dition. However,  from  recent  researches,  it  is  quite 
certain  that  its  pathogenesis  does  not  rest  either  in 
the  muscles  or  the  spinal  cord,  although  these  may  and 
often  do  show  secondary  changes.  The  association 
disease,  as  well  as  simple  myoclonus,  is  probably 
cerebral  in  origin.  Its  type  of  cortical  degeneration 
should  be  somewhat  analogous  to  that  of  paralysis 
agitans,  chronic  and  senile  chorea,  and  the  like  chronic 
convulsive  disorders  which  develop  upon  a  soil  of 
degeneracy,  plus  some  sort  of  autointoxication,  pos- 
sibly thyroidal  in  origin,  as  Lundborg  has  recently 
urged.  As  to  the  histocytologic  changes  in  the  cortex, 
the  conclusions  of  Clark  and  Prout,  who  carefully 
studied  it  in  one  case  under  ideal  conditions,  are 
worthy  of  attention,  inasmuch  as  they  form  a  material 
basis  to  the  conclusions  of  Raymond,  Ribot,  Dide, 
Venga,  and  Gonzales,  and  others  who  state  that  its 
real  pathology  is  cortical.  They  believe  that  the  lesion 
of  myoclonus-epilepsy  is  in  the  cerebral  cortex,  in- 
volving the  nucleus  and  the  intranuclear  network  of 
cells  of  both  sensory  and  motor  types.  Its  patho- 
genesis appears  to  be  an  intoxication  or  autointoxica- 
tion of  these  cortical  cells,  probably  brought  about  by 
a  faulty  chemotaxis  of  these  same  cells  because  of  an 
inherent  organic  anomaly.     While  the    epilepsy  and 


FREQUENCY    AND    TIME    OF    SEIZURES.  193 

the  myoclonus  maintain  their  separate  morbid  entity, 
the  two  are  closely  allied,  and  indeed  are  often  found 
as  indissolubly  associated  clinically  and  pathologically 
as  are  the  motor  and  sensory  functions  of  the  cells 
they  involve. 

FREQUENCY  AND  TIME  OF  EPILEPTIC  SEIZURES. 

Epileptic  attacks  occur  in  point  of  frequency  any- 
where from  once  a  year  or  less  often  up  to  several 
hundred  a  day.  The  greatest  number  of  well-defined 
attacks  in  one  hour  that  have  come  under  my  obser- 
vation in  one  day  was  280;  another  patient  had  519 
in  forty-nine  hours,  dying  at  the  end  of  that  time  in 
status  epilepticus.  The  convulsions  in  this  case  were 
general;   in  the  former  they  were  mostly  Jacksonian. 

J.  P.  in  seven  years  had  attacks  as  follows : 

Year.  Day.  Night.  Total. 

1896 236  154  390 

1897 538  641  1179 

1898 465  517  982 

1899 578  633  1211 

1900 367  533         9°° 

1901 275  28i         556 

1902 302  306         608 

Total 5826 

E.  C.  in  five  years  had  26,124  petit  mal  and  psychic 
attacks  in  alternation,  which  failed  to  impair  her 
mental  faculties  in  any  respect. 

Year.  Day.  Night.  Total. 

1898 2784  18  2802 

1899 6239  157  6396 

i9°° 7*45  J3  7158 

1901  8878  717  9595 

i9°2 173  x73 

Total 26,124 

In  1374  cases  under  my  observation  the  approxi- 
mate frequency  of  the  attacks  was  as  follows : 


194 


SEIZURE    TYPES- 


Weekly  or  more  often in  775 — 56  per  cent. 

Every  two  weeks 

Every  three  weeks 

Every  four  weeks 

Every  eight  weeks 

Every  twelve  weeks 

Everv  six  months  or  over 


"  173- 

-I2j  " 

'  61- 

-4i 

"  244- 

-i7i   " 

"  42- 

-  3 

"  49- 

-3i    " 

30 


It  is  understood  that  these  frequency  periods  are 
approximate  only.  Few  cases,  save  those  in  the  four- 
weeks  period — most  of  which  are  in  women — show 
any  fixed  periodicity.  The  greater  number  in  the 
four-weeks  period  is  accounted  for  by  the  stress  in- 
cident to  the  menstrual  flow.  Among  those  having 
attacks  weekly  or  more  often,  half  or  more  have 
attacks  daily  or  several  times  a  day. 

The  following  diagram  shows  the  number  of  seizures 
by  hours  at  the  Craig  Colony  during  the  year  1902. 
The  summary  includes  100,296  seizures;  41,423  in 
females,  58,873  in  males. 


Hour  of 

Number 

attack. 

attacks. 

I  A.  M. 

3793 

2  A.  M. 

5OI7 

3  A.M. 

5746 

4  A.  M. 

4652 

5  A.  M. 

3712 

6  A.  M. 

4204 

7  A.  M. 

4258 

8  A.  M. 

4581 

9  A.  M. 

4413 

IO  A.  M. 

4420 

II  A.  M. 

4562 

12  Noon 

4082 

I  P.  M. 

4120 

2  P.  M. 

4132 

3  p-m. 

4189 

4  P.  M. 

3763 

5  p-m. 

3594 

6  P.  M. 

3865 

7  P.  M. 

3256 

8  P.  M. 

377i 

9  P.  M. 

.4649 

IO  P.  M. 

4184 

IIP.  M. 

3935 

12  Mdnt. 

33°7 

CHAPTER  VII. 

STATUS  EPILEPTICUS. 

By  l.  Pierce  Clark,  M.D. 

Synonyms:  Etat  de  mal;  Acute  Epilepsy. 

Historic— The  first  scientific  study  of  status  epi- 
lepticus  was  begun  in  the  early  part  of  the  twentieth 
century  at  the  Salpdtriere  and  Bice'tre  Hospitals  of 
Paris.  It  was  called  "etat  de  mal"  by  Bouchet  and 
Cazauvielh  in  their  work  upon  the  condition  in  1825. 
Bourneville's  name,  however,  is  most  deservedly  con- 
nected with  our  present  knowledge  of  the  subject,  as 
his  works  cover  a  period  of  the  past  thirty  years. 

While  some  think  the  condition  of  status  to  be  rare 
(largely  found  in  asylums),  most  epileptologists  be- 
lieve it  is  one  of  the  chief  factors  in  mortality  statis- 
tics of  epileptics  both  in  and  outside  special  institu- 
tions for  this  class.  Status  epilepticus  is  the  true 
climax  of  epilepsy;  that  is,  an  epileptic  is  foredoomed 
to  die  of  the  status  as  the  maximum  development 
of  the  disease,  if  all  possible  complications  such  as 
intercurrent  affections  are  removed.  Although  there 
are  notes  of  at  least  300  or  400  cases  of  the  status  in 
medical  literature  in  which  fairly  accurate  data  of  a 
clinical  nature  may  be  obtained,  yet  careful  and  com- 
plete clinico-pathologic  studies  of  even  a  few  cases  are 
comparatively  rare. 

Definition. — As  to  what  constitutes  status,  author- 
ities still  differ,  and  it  is  still  without  exact  definition. 
For  typical  cases,  however,  the  condition  may  be  de- 
fined as  follows:  Status  epilepticus  is  the  maximum 
development  of  epilepsy  in  which  one  paroxysm  follows 

195 


196  STATUS    EPILEPTICUS. 

another  so  closely  that  the  coma  and  exhaustion  are 
continuous  between  seizures.  It  is  sooner  or  later 
attended  by  a  marked  rise  in  temperature,  pulse,  and 
respiratory  frequency.  The  latter  accompaniments  are 
the  indices  to  the  degree  of  exhaustion  and  its  fatality. 

As  status  is  confined  largely  to  the  grand  mat  form 
of  epilepsy  its  variations  are  obviously  less  bizarre  in 
their  exhibition  than  epilepsy  proper.  However,  in 
rare  instances  it  may  be  composed  of  equivalents  such 
as  delirium,  stupor  or  coma,  cough  or  hiccough,  and 
a  variety  of  psychic  states  which  have  for  their  bases 
cortical  discharges  resulting  in  more  or  less  complete 
physical  and  psychic  exhaustion.  From  the  convul- 
sive standpoint,  however,  status  is  usually  composed 
of  ordinary  grand  mat  seizures  which  preserve  their 
individuality  or  become  imbricated  tonic  or  clonic 
spasms.  The  seizures  may  be  lacking  in  tonic  or 
clonic  elements,  but  the  former  is  the  one  usually 
curtailed  if  either  is  omitted.  Status  periods  com- 
posed entirely  of  tetanoid  or  statuesque  attacks  are 
not  unknown  (Clark).  Bourneville  has  attempted 
to  classify  true  status  epilepticus  into  three  or  four 
different  varieties,  and  serial  periods  into  two  classes, 
but  a  real  difference  in  types  of  status  does  not  exist, 
and  serial  attacks  are  but  stepping-stones  to  status, 
depending  much  upon  the  nature  of  treatment  em- 
ployed whether  or  not  they  may  end  in  true  status. 

Forms  of  Epilepsy  in  which  Status  Occurs. — It 
usually  appears  in  those  cases  of  idiopathic  epilepsy 
in  which  grand  mal  seizures  predominate.  It  may 
occur  in  psychic   epilepsy.*     Fatal  status,   however, 

*  I  desire  to  call  especial  attention  to  the  form  of  status  that  follows 
psychic  seizures.  It  is  attended  by  a  few  light  convulsive  movements  only, 
often  so  light  as  to  almost  pass  unobserved,  the  patient  quickly  sinking  into 
coma  with  increasing  temperature  elevation  until  death  supervenes,  often 
within  a  few  hours.  It  is  interesting  chiefly  on  account  of  the  gravity  of 
the  condition  as  compared  with  the  apparent  insignificance  of  the  convul- 
sions that  led  to  its  creation.     (Spratling.) 


STATUS    EPILEPTICUS.  197 

is  most  often  recruited  from  the  grand  mal  type.  No 
definite  rule  can  be  laid  down  governing  the  occurrence 
of  status  in  any  particular  case  of  simple  idiopathic 
grand  mal  epilepsy,  with  the  exception  that  those 
liable  to  serial  attacks  are  most  frequently  selected 
for  status.  All  symptomatic  epilepsies  dependent 
upon  gross  organic  brain  lesions,  such  as  trauma, 
abscess,  tumor,  thrombus,  and  infantile  hemiplegia, 
are  particularly  prone  to  develop  status  (unilateralis) . 
They  usually  die  in  this  state  ultimately.  Status 
pareticus  is  an  instance  of  cerebral  disease  often 
terminating  in  status.  There  is  a  close  analogy 
between  all  convulsive  phenomena,  and  the  different 
manifestations  of  status  resulting  from  different  brain 
lesions  must  bear  a  close  relationship  to  the  status  of 
epilepsy  both  from  a  histocytologic  and  physiopatho- 
logic  view-point.  Status  is  a  notable  ending  to  all 
partial  Jacksonian  epilepsy.  A  third  of  the  status 
cases  on  record  have  been  at  bottom  dependent 
upon  organic  lesions  of  the  cortex.  However,  its 
mono-  or  hemispastic  character  greatly  lessens  the 
possibility  of  the  fatal  character  of  individual  status 
periods.  Such  cases  often  have  several  periods  before 
the  fatal  one.  Local  transitory  paralysis  often  occurs 
in  such  cases.  Jackson  and  Gowers  believe  that  the 
latter  symptoms  are  pathognomonic  of  status;  still 
later  data,  however,  show  that  exhaustion  paralysis  is 
not  a  constant  symptom  of  status  (Clark  and  Prout) . 

Sex. — The  influence  of  sex  is  of  little  moment  in 
the  status  production.  Lorenz  and  Bourneville,  how- 
ever, believe  women  are  twice  as  frequently  affected 
as  men,  but  in  one  hundred  and  eleven  cases  collected 
from  literature,  sixty-seven  were  men  and  forty-four 
were  women.  The  mortality  rate  between  the  two 
sexes  is  about  equal  (in  sixty  cases  twenty-eight  were 
men,  thirty-two  were  women).  If  the  hereditary 
factor  of  epilepsy  were  of  less  moment  in  the  pro- 


198  STATUS    EPILEPTICUS. 

duction  of  epilepsy  proper,  it  is  possible  that  the 
difference  in  sex,  including  difference  of  manner  of 
life,  occupation,  etc.,  would  be  greater  factors  in 
determining   sex   preference   than   at   present   exists. 

Age. — There  is  no  particular  age  at  which  status  is 
apt  to  develop.  Its  slightly  increased  frequency  at  a 
particular  epoch  is  due  to  the  fact  that  epilepsy  itself 
develops  more  especially  at  certain  ages.  In  rare 
instances  status  may  develop  in  earliest  childhood. 
Thus  W.  Ramsey  Smith  reports  two  cases,  one  of  a 
child  of  three  who  died  of  it,  and  another  of  four  who 
had  typical  status  and  recovered.  Such  cases  could 
hardly  be  ranked  with  the  statistics  of  idiopathic  epi- 
lepsy of  the  adult,  and  were  probably  due  to  gross 
cerebral  disease. 

It  is  the  general  rule  for  infantile  cerebral  palsy  to  be 
ushered  in  by  convulsions  which  are  either  partial  or 
general  with  local  onset  and  comprised  in  serial  or  status 
periods;  but  from  a  pathogenetic  standpoint  such 
cases  cannot  be  regarded  as  the  status  of  epilepsy 
per  se,  which  develops  long  after  the  disease  is  first 
inaugurated.  While  it  is  by  no  means  uncommon  to 
see  status  in  extremely  aged  epileptics  (of  seventy  or 
eighty  years),  senile  patients  usually  die  of  status 
apoplecticus  from  arterial  rupture,  sclerotic  changes 
being  the  primary  cause  of  the  epilepsy  itself. 

Menstruation. — The  influence  of  menstruation  is 
nil,  much  less  so  even  than  in  inducing  epilepsy  proper. 
Usually  the  occurrence  of  serial  attacks  at  menstrua- 
tion in  an  individual  not  previously  known  to  be  epi- 
leptic confirms  the  diagnosis  of  status  hystericus 
which  usually  occurs  at  this  epoch.  It  is,  however, 
most  unfortunate  that  grand  hysteria  in  its  status 
form  is  at  times  so  intimately  blended  with  the  true 
symptoms  of  status  epilepticus  that  it  is  often  im- 
possible for  even  the  most  expert  to  make  more  than  a 
provisional  diagnosis  until  the  history  and  cardinal 


STATUS    EPILEPTICUS. 


199 


curves  (fever,  pulse,  and  respiration)  are  at  hand  to 
make  certain  the  diagnosis;  happily  such  problems 
are  of  rare  occurrence  (see  clinical  charts).  A  few- 
epileptics  have  hysteria  which  in  turn  develops  into 
status  at  the  menstrual  period,  while  the  same  patient 
may  have  status  epilepticus  between  the  menstrual 
periods.  Classic  status  epilepticus  is  not  more  difficult 
to  differentiate  from  typical  status  than  essential  epi- 
lepsy from  major  hysteria,  but  unfortunately  there  are 


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Fig.  9. — Chart  showing  the  clinical  relationship  between  the  tempera- 
ture, pulse,  respiration,  and  epileptic  seizures  in  a  typical  fatal  case  of  status 
epilepticus.  The  hourly  record  of  seizures  takes  its  reading  standard  at 
the  right. 

many  variations  in  the  manifestations  of  both  dis- 
eases, which  the  most  experienced  fail  to  differentiate 
(Steffins). 

Interval  between  the  First  Epileptic  Attack  and 
Status  Epilepticus. — Of  forty-two  cases  reported  from 
the  Craig  Colony  (Clark  and  Prout),  in  nineteen  who 
developed  their  disease  between  birth  and  four  years 
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200 


STATUS    EPILEPTICUS. 


developing  epilepsy  between  ten  and  fourteen  the 
average  was  six;  in  two  developing  over  thirty  the 
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facts  seems  to  show  that  in  epilepsies  developed  in 
the  later  epochs  of  life  the  onset  of  status  is  delayed 
for  a  longer  period  of  time  than  in  infancy;  the  data, 


STATUS    EPILEPTICUS.  201 

however,  are  too  meager  to  be  more  than  suggestive. 
Within  general  limits  it  may  be  said  that  epilepsy  must 
be  well  developed  before  status  will  supervene.  The 
period  of  time  may  vary  from  a  few  to  many  years. 
In  making  the  prognosis  of  the  occurrence  of  status 
in  any  given  cases,  predisposition,  the  excitant,  the 
form  of  epilepsy,  and  the  course  which  the  disease 
has  already  taken,  particularly  as  regards  its  tendency 
to  exhibit  itself  in  groups  or  serial  periods,  must  be 
reckoned  with. 

Intervals  between  Status  Periods  in  the  Same  Case. — 
No  definite  time  exists  between  status  periods  in  the 
same  case.  A  period  of  days,  weeks,  months,  or  years 
may  intervene.  The  patient  may  have  but  one  status 
period  and  recover  not  only  from  the  status,  but  the 
epilepsy  itself,  although  this  termination  is  rare  indeed. 
Generally  one  attack  of  status  paves  the  way  for  an- 
other, and,  in  fact,  there  is  no  limit  to  the  number  of 
status  periods  that  may  occur  before  death  supervenes. 
Although  Bourne ville  and  Lorenz  state  that  no  in- 
dividual case  may  have  more  than  three  or  four 
status  periods,  it  is  possible  for  as  many  as  six  or  seven 
to  occur.  In  one  case  the  patient  had  nine  typical 
attacks  (Clark  and  Prout).  As  a  rule,  three  or  four 
status  periods  in  idiopathic  epilepsy  cause  death, 
while  innumerable  periods  of  status  epilepticus  uni- 
lateralis  may  occur  in  hemiplegic  epileptics  and  death 
not  supervene. 

In  proportion  as  the  individual  paroxysms  of  the 
status  period  fall  short  in  point  of  severity  from  typical 
grand  mat,  so  does  the  gravity  of  that  particular  status 
lessen  and  the  more  partial  or  focal  (or  in  which  seizures 
are  Jacksonian  in  the  order  of  beginning),  the  longer 
may  the  individual  withstand  the  exhaustion  of  the 
status. 

The  Immediate  Cause  of  Status  Epilepticus. — As 
status  is  the  climax  of  all  idiopathic  epilepsy  the  im- 


202  STATUS    EPILEPTICUS. 

portance  of  this  section  is  lessened.  The  exciting 
factors  are  none  other  than  those  subtle  causes  which 
underlie  the  continuity  of  the  disease  itself.  There 
are  varying  degrees  of  epilepsy,  the  severity  of  which 
are  not  at  all  portrayed  in  the  paroxysmal  frequency 
of  the  disease,  for  example,  as  the  degree  of  sensory 
and  mental  changes.  This  fact  accounts  for  the  often 
surprising  suddenness  with  which  status  supervenes. 
To  be  classed  with  the  natural  factors  in  causing 
status,  the  artificial  one  of  a  too  sudden  withdrawal 
or  alteration  of  sedatives  should  be  noted.  Status 
precipitated  in  this  manner  is  almost  incapable  of 
control  by  a  renewed  administration  of  even  the  most 
potent  sedatives.  Probably  at  least  a  third  of  the 
fatal  status  cases  on  record  are  due  to  this  cause  either 
directly  or  indirectly. 

Inception-symptomatology  of  the  Status. — As  a  rule, 
the  absence  of  prodromes  is  not  a  striking  phenomena, 
but  in  the  great  majority  of  cases  it  is  heralded  by  a 
steady  increase  of  the  paroxysmal  frequency  of  the 
epilepsy  either  in  series  or  in  a  gradual  daily  increase 
of  attacks  spread  more  or  less  evenly  over  varying 
periods  of  time.  A  history  of  serial  attacks  ranging 
from  five  to  fifteen  or  even  twenty-five  paroxysms 
in  twenty-four  hours  is  the  rule.  Usually  where 
status  occurs  in  a  fulminating  manner,  the  absence  of 
a  preceding  serial  period  is  explainable  on  the  basis 
of  large  doses  of  bromids,  a  gradually  increased  seda- 
tion in  the  face  of  threatened  attacks.  Prolonged 
sedation  of  bromids  alters  the  natural  types  of  status 
in  many  ways. 

Clinical  Picture  of  a  Typical  Status  Case. — For  the 
sake  of  clinical  description  status  is  usually  divided 
into  two  stages,  a  stuporous  and  convulsive  stage. 
Usually  one  seizure  of  the  grand  mat  type  follows 
another  of  the'  same  character  a  few  minutes  or  seconds 
apart.     Often  the  attacks  are  an  hour  apart  for  the 


STATUS    EPILEPTICUS.  203 

first  five  or  ten  seizures.  Each  attack  is  complete 
and  separate,  maintaining  its  peculiar  type  common 
to  the  individual  case.  In  Jacksonian  or,  better, 
partial  epilepsy,  the  isolated  attack  holds  a  distinct 
order  of  invasion  so  long  as  exhaustion  is  not  extreme. 
At  first  consciousness  is  completely  regained  between 
paroxysms;  later  on,  as  the  periods  between  shorten, 
consciousness  is  but  partly  regained,  there  is  a  marked 
disorientation,  and  finally  the  comatose  state  is  not 
rallied  from  between  attacks,  and  the  stupor  deepens 
into  profound  coma.  All  cases,  idiopathic  or  partial, 
in  which  an  order  of  muscular  march  obtains,  the  subse- 
quent coma  is  less  profound  and  the  status  in  conse- 
quence is  less  severe.  As  the  attacks  culminate  in  their 
greatest  frequency,  the  periods  of  rest  between  con- 
vulsions may  be  entirely  omitted  and  some  part  of  the 
body  may  remain  continually  in  spasm.  The  part  last 
involved  in  convulsion  does  not  cease  from  agitation 
before  the  muscles  engaged  in  the  initial  stage  of  the 
next  paroxysm  begin  again  to  sweep  the  rounds  of  the 
muscular  invasion  of  the  next  fit.  The  spasm  may  be 
essentially  clonic  or  there  may  be  a  slight  lessening 
of  the  paroxysmal  intensity,  thus  marking  the  end 
and  the  beginning  of  isolated  discharges;  this  over- 
lapping is  almost  always  seen  in  the  climax  of  the  con- 
vulsive stage  of  fatal  status.  With  the  increasing  fre- 
quency of  attacks  the  paroxysms  usually  diminish  in  in- 
tensity, and  the  tonic  period  if  present  at  the  beginning 
may  be  abbreviated  or  omitted  entirely  in  the  advanced 
status.  The  seizure  at  the  end  of  the  convulsive 
stage  may  be  localized  to  a  single  muscle  or  a  small 
group  of  muscles.  Generally  in  these  status  periods 
composed  of  fulminant  convulsions  (of  general  and 
simultaneous  body  involvement),  the  end  of  the  con- 
vulsive stage  presents  only  slight  general  or  fibrillary 
tremor  over  the  entire  body. 

As    the    exhaustion    increases    after    the    first    few 


204  STATUS    EPILEPTICUS. 

attacks,  there  is  elevation  of  temperature,  increased 
pulse  rate,  and  respiratory  frequency.  The  pulse  and 
temperature  may  surmount  to  a  great  height;  tem- 
perature 1070  or  1080  F.,  and  pulse  160  to  200  per 
minute.  At  last  the  convulsions  lessen  in  frequency 
and  the  stuporous  stage  is  ushered  in  with  coma  or 
collapse,  which  is  quite  analogous  to  the  coma  of 
typhus  or  typhoid.  The  state  is  but  the  resultant 
exhaustion  of  the  convulsive  stage.  The  mouth  is  foul, 
the  tongue  dry  and  fissured,  and  the  skin  is  covered 
with  cold  clammy  sweat ;  swallowing  becomes  difficult 
or  impossible.  The  urine  is  usually  voided  and  stools 
may  be  passed  involuntarily.  While  the  patient  may 
die  in  the  throes  of  the  convulsive  stage  in  fatal  status, 
a  few  hours  are  usually  passed  at  least  in  the  stage 
of  coma  before  death.  Even  in  well-advanced  coma 
slight  convulsive  tremors  may  occur  from  time  to 
time. 

All  reflexes  are  abolished  in  the  coma,  the  respiration 
becomes  loud,  noisy,  and  stertorous  in  character,  and 
the  temperature  and  pulse  may  undergo  marked 
alteration  depending  upon  the  frequency  and  intensity 
of  the  foregoing  symptoms.  Death  may  terminate  the 
stuporous  stage  at  any  time.  If  recovery  is  to  occur, 
coma  wears  away  and  is  slowly  replaced  by  stupor 
which  in  turn  is  often  followed  by  mild  delirium  or 
hallucinations.  The  latter  state  of  severe  exhaustion 
is  finally  replaced  by  a  more  or  less  rapid  convalescence 
and  the  patient  ultimately  resumes  the  pre-status 
condition  in  the  course  of  a  week.  As  a  rule,  if  re- 
covery does  not  follow  more  or  less  promptly,  a  low 
muttering  delirium  supervenes;  extensive  sloughing 
of  the  nates  follows  and  life  itself  is  more  or  less  sud- 
denly terminated.  The  foregoing  constitutes  in  gen- 
eral terms'  the  usual  clinical  picture  of  status  epilep- 
ticus. 

Seizures  may  occur  from   50  to   200  a  day.     The 


STATUS    EPILEPTICUS.  205 

highest  record  of  grand  mal  attacks  for  any  one  case 
is  probably  held  by  one  of  Leroy's  in  which  there  were 
488  attacks  in  twenty-four  hours;  the  patient  had 
1000  attacks  in  three  days;  the  status  ended  fatally. 
Some  American  writers  have  recently  alluded  to  the 
extraordinary  number  of  attacks  which  have  taken 
place  within  a  period  of  several  weeks.  Thus,  Parsons 
reports  1400  attacks  in  four  weeks,  others  2000  and 
even  3000  in  similar  periods.  Such  statistics  belong 
to  epilepsy  proper,  as  status  does  not  extend  over  such 
a  long  period  of  time. 

The  duration  of  the  convulsive  stage  is  very  variable, 
it  may  last  between  three  or  four  hours  or  it  may 
extend  over  a  period  of  several  days.  A  case  is  re- 
ported which  persisted  for  one  week  (Clark  and  Prout) . 
As  a  general  rule,  however,  the  convulsive  stage  lasts 
from  eight  or  ten  hours  to  three  or  four  days.  It 
forms  from  about  a  third  to  a  half  of  the  whole  status 
period.  The  duration  of  status  in  its  entirety  is 
usually  not  less  than  twenty  hours  or  over  twelve 
days,  if  both  stages  are  present;  not  infrequently 
patients  may  die  in  the  convulsive  stage  after  five  or 
six  hours  in  paroxysms.  In  130  cases  all  were  within 
the  limit.  If  either  stage  of  status  is  curtailed  it  is 
the  stuporous.  About  a  third  of  the  fatal  cases  have 
no  real  stage  of  coma,  there  being  but  a  few  moments' 
cessation  of  attacks  before  the  death  agony.* 

Diagnosis. — When  the  history  of  genuine  epilepsy  is 
obtainable  the  diagnosis  is,  as  a  rule,  comparatively 
easy  by  considering  the  presence  or  absence  of  the 
cardinal  symptoms  (fever,  pulse,  and  respiratory 
curves).  (See  clinical  charts  for  illustrations  in  diag- 
nosis.) 

Prognosis. — The  prognosis  of  status  is  necessarily 
grave,  knowing  it  to  be  the  severest  form  of  the  epilep- 

*  For  the  pathology  of  status  the  reader  is  referred  to  the  special  chapter 
on  this  subject. 


2o6  STATUS    EPILEPTICUS. 

tic  state.  A  low  temperature  is  not  necessarily  a 
favorable  symptom,  while  there  have  been  numerous 
recoveries  with  temperatures  of  1040  and  1060  F. 
Even  a  temperature  of  1070  F.  is  not  absolutely  prog- 
nostic of  death  as  Lorenz  holds  (Clark  and  Prout).  A 
patient  at  the  Craig  Colony  recovered,  although  the 
temperature  reached  1090  F.  (Spratling).  The  indi- 
vidual resistance,  the  suddenness  of  onset,  and  the 
general  severity  of  the  attack  must  enter  into  a  com- 
prehensive prognosis,  as  well  as  a  knowledge  of  the 
cardinal  curves.  Extreme  paralysis  of  the  pharynx 
is  an  unfavorable  symptom,  but  many  patients  have 
this  symptom  well  marked  and  yet  recover.  Often 
for  a  few  days  after  convalescence,  the  patient  still 
suffers  from  difficulty  in  swallowing,  which  is  fre- 
quently accompanied  by  nasal  regurgitation. 

The  duration  of  the  status  is  not  an  absolute  factor 
in  prognosis,  as  Bourneville  has  held;  patients  may 
recover  after  nine,  ten,  or  even  twelve  days'  duration 
of  the  disease  and  die  in  a  subsequent  status  of  a  much 
shorter  duration. 

Usually  status  unilateralis  is  markedly  prolonged 
without  being  fatal.  In  proportion  as  the  paroxysm 
of  any  status  case  varies  from  idiopathic  grand  mal 
without  order  of  invasion,  the  possibility  of  a  fatal 
termination  lessens.  The  shorter  the  inter-paroxys- 
mal periods  of  rest  between  the  first  attack  the  worse 
the  prognosis.  In  such  cases  acute  exhaustion  in  the 
convulsive  stage  is  imminent  and  only  the  strongest 
sedatives  are  of  avail.  To  be  able  to  postpone  the 
paroxysm  as  soon  as  the  first  frequency  of  the  status 
onset  occurs  is  the  strategic  point  in  the  treatment, 
hence  the  prognosis  is  based  in  no  small  degree  upon 
the  efficiency  of  early  emergency  treatment.  A  sud- 
den rise  or  fall  in  any  one  of  the  cardinal  curves,  a 
sudden  cessation  of  convulsions  without  evidence  of 
returning  consciousness  are  absolutely  prognostic  of 


STATUS   EPILEPTICUS.  207 

death.  Changes  of  this  sort  always  occur  in  fatal 
status,  usually  from  six  to  eight  hours  before  death. 

Before  Lorenz  collected  the  notes  of  eighty  cases 
from  different  authors  the  mortality  was  held  by 
Nothnagel,  Binswanger,  and  Legrand  du  Saulle  at  a 
little  more  than  50  per  cent.  Lorenz  placed  it,  how- 
ever, at  less  than  45  per  cent.  Clark  and  Prout  place 
it  at  33^-  per  cent,  in  the  study  of  fifty-two  cases  of 
status. 

It  is  but  just  to  compute  the  mortality  from  status 
upon  the  total  number  of  status  periods,  instead  of 
individual  cases  treated,  which,  in  the  statistics  of  100 
status  periods  occurring  at  Craig  Colony,  place  the 
mortality  at  14  per  cent.  It  may  be  laid  down  as  a 
general  rule  that  the  gradual,  deliberate,  step-like  in- 
crease of  the  cardinal  symptoms  in  spite  of  sedatives 
renders  prognosis  as  absolutely  unfavorable. 

TREATMENT. 

Prophylaxis. — The  prophylactic  treatment  of  the 
status  is  of  great  importance.  If  serial  attacks  are 
presented  in  the  history,  sedatives  must  be  employed 
to  check  the  periodicity  of  attacks,  which  can  largely 
be  accomplished  by  giving  bromids  at  the  threatened 
periods  in  sufficient  quantities  to  partly  suppress  the 
convulsions,  thus  spreading  out  or  prolonging  the 
period  of  discharge,  and  in  this  manner  the  exhaustion 
is  lessened  for  any  particular  period. 

In  case  there  is  a  gradually  increasing  paroxysmal 
frequency,  bromids  in  high  dosage  must  be  employed ; 
any  sudden  decrease  or  withdrawal  of  bromids  may 
precipitate  status;  a  large  percentage  of  status  cases 
in  general  practice  are  induced  by  such  indiscretions. 
The  long  account  of  suppressed  paroxysms  is  then  paid 
for  by  a  status  condition  which  frequently  terminates 
the  patient's  life.  Cases  in  which  there  is  a  sudden 
and    prolonged    suppression    of    attack    need    careful 


208  STATUS    EPILEPTICUS. 

watching,  as  they  constitute  a  certain  percentage  of 
the  status  statistics.  For  these  cases  the  emergency 
prescription  for  an  incipient  status  should  be  in  readi- 
ness. The  formula  for  the  emergency  prescription  has 
been  used  with  unusually  good  results.  It  was  first 
used  by  me  in  1896,  and  in  a  slightly  modified  form 
it  has  been  constantly  employed  in  all  threatened 
status.  The  formula  and  directions  for  using  the 
same  are: 

R  .     Tr.  Opii  Deod r^   v. 

Potass.  Bromid gr.  xxv. 

Chlor.  Hydt gr.  xx. 

Liq.  Morph.  Sulph.  (U.  S.) 31.  M. 

Sig. — One  dose;  repeat  in  two  hours  if  necessary. 

An  explanation  of  the  efficacy  of  this  prescription 
might  be  made  on  the  following  principle :  The  chloral 
and  morphin  are  the  first  to  act  in  their  respective 
order,  the  chloral  as  a  sedative  upon  the  vascular 
system  and  especially  upon  the  blood-supply  to  the 
brain;  the  morphin  as  a  sedative  on  the  nerve  cells. 
Following  their  immediate  combined  action  we  obtain 
the  slower  and  more  permanent  sedative  effects  of 
the  bromid  and  opium  upon  the  cerebral  centers. 

One  experienced  in  the  care  of  epileptics  becomes 
watchful  for  the  possible  occurrence  of  status,  and 
consequently  employs  methods  in  the  general  treat- 
ment of  the  disease  which  will  lessen  the  impetuosity 
of  a  threatened  status  period.  In  chronic  epileptics 
in  whom  serial  or  pseudo-status  is  liable  of  frequent 
occurrence,  the  bromids  need  to  be  given  between 
periods  with  the  greatest  caution,  in  order  that  the 
full  sedation  of  the  salt  may  be  used  effectually  at  the 
status  crisis;  in  other  words,  a  certain  reserve  must 
be  held  for  the  paroxysmal  climax.  The  employment 
of  all  remedies  favorable  to  the  general  amelioration 
of  the  epileptic  state  should  be  the  general  rule  in  pro- 
phylactic treatment  of  status. 


STATUS    EPILEPTICUS.  209 

The  surgical  treatment  of  status  is  relatively  unim- 
portant; status  of  idiopathic  grand  mal  cannot  be 
successfully  treated  by  any  known  surgical  procedure, 
either  from  clinical  or  pathologic  considerations,  and 
therefore  operative  interference  is  not  justifiable  in 
idiopathics.  Trephining  on  the  basis  of  the  late 
revival  of  the  old  theory— whose  ghost  has  just  been 
laid  again — that  the  status  is  the  result  of  an  increase 
of  intracranial  pressure,  has  not  alleviated  the  con- 
vulsions of  the  status  condition  to  any  appreciable 
extent.  However,  trephining  for  the  status  epilepti- 
formis,  caused  by  a  recent  trauma,  is  imperative  and 
its  early  adoption  is  attended  by  the  most  brilliant 
results  (Mynter  and  Krauss),  but  the  surgical  treat- 
ment of  this  form  of  epilepsy  should  never  be  post- 
poned until  the  status  develops.  Operation  should  be 
undertaken  as  soon  as  the  influence  of  the  trauma  can 
be  determined.  The  status  of  old  organic  lesions,  such 
as  the  old  infantile  cerebral  palsies,  is  hardly  operable ; 
it  should  be  considered  in  the  class  of  idiopathic 
epilepsy,  so  far  as  treatment  is  concerned. 

It  may  appear  from  the  conservative  standpoint  of 
this  chapter  that  status,  being  but  a  climax  of  epilepsy 
proper,  is  therefore  not  preventable  until  we  are  able 
to  modify  the  underlying  tissue  changes  in  the  cerebral 
cortex.  However,  many  status  periods  are  aborted  by 
proper  treatment  of  the  epilepsy,  as  well  as  the  status 
itself.  Not  only  may  the  life  of  the  patient  be  saved, 
but  the  patient  may  recover  in  rare  instances  from 
the  epilepsy  itself.  The  present  mortality  from  status 
can  be  further  decreased  to  a  marked  extent  by  resort- 
ing to  prompt  treatment  in  the  convulsive  stage.  If 
the  seizures  cannot  be  entirely  controlled  in  all  cases, 
it  is  generally  possible  to  lessen  the  paroxysmal  fre- 
quency and  thus  conserve  the  organism  from  acute 
exhaustion,  the  most  fatal  sequence  of  status.  In- 
deed, the  condition  of  acute  exhaustion  stands  in  the 


2IO  STATUS    EPILEPTICUS. 

same  sequential  relation  to  death  by  status  as  status 
does  to  epilepsy  proper. 

Treatment  of  the  Convulsive  Stage. — After  the  first 
five  or  six  paroxysms,  the  emergency  prescription 
heretofore  mentioned  should  be  given.  In  the  fifteen 
or  twenty  minutes  necessary  for  the  remedy  to  take 
effect,  chloroform  should  be  employed  to  immediately 
lessen  the  severity  and  number  of  paroxysms.  This 
anesthetic  must  be  administered  [to  the  point  of  com- 
plete surgical  anesthesia  in  order  to  be  effective  in 
controlling  the  convulsions.  It  must  always  be  borne 
in  mind  that  that  which  is  indicated  for  the  convulsive 
period  is  contraindicated  for  the  subsequent  stuporous 
stage;  therefore  antispasmodics  must  be  given  with  due 
caution. 

Delasiauve  has  recommended  general  and  local 
blood-letting,  drastic  cathartics,  ice  to  the  head,  and 
quinin  by  rectum.  Bourneville  and  some  other 
French  writers  claim  to  still  hold  this  plan  beneficial. 
iVcting  upon  the  theory  that  venesection  lessens 
toxicity  of  the  abnormal  accumulation  of  waste  prod- 
ucts (toxins)  in  the  blood,  the  plan  of  blood-letting  is 
a  good  one.  Venesection  in  status  finds  its  greatest 
value  when  employed  in  plethoric  epileptics.  Status 
only  too  frequently  occurs  in  the  feeble  instead  of  the 
robust;  usually  not  more  than  a  third  of  status  cases 
are  in  normal  bodily  vigor  at  their  status  periods.  A 
better  practice  is  to  venesect  and  inject  saline  solution. 
This  method,  as  it  doubly  reduces  the  toxicity  of  the 
blood,  deserves  first  place  after  the  emergency  treat- 
ment of  status  has  been  tried  and  found  inefficient. 
As  for  venesecting  for  the  supposed  increased  intra- 
cranial and  arterial  pressure,  the  condition  has  no 
basis  in  fact;  on  the  contrary,  Fere  has  shown  that 
intracranial  and  arterial  pressure  is  markedly  dimin- 
ished in  status,  and  Nornatsky  and  Arndt  have  re- 
cently  conclusively    demonstrated   by   the   elaborate 


STATUS    EPILEPTICUS.  211 

experiments  upon  isolated  convulsions,  serial  and 
status  periods,  that  the  increase  of  intracranial  pres- 
sure is  only  a  result  and  not  a  cause  of  epilepsy. 

If  drastic  cathartics  are  given  early,  they  may  be 
of  use ;  in  the  later  stages  they  are  brought  into  action 
with  great  difficulty.  The  application  of  ice  to  the 
head  in  the  convulsive  stage  is  to  be  discouraged, 
especially  so  as  the  coma  becomes  continuous.  It  has 
its  advocacy  in  the  early  belief  that  status  was  a 
meningitic  affection.  Ice  to  the  head  may  be  em- 
ployed in  convalescence,  as  it  appears  to  lessen  the  post 
status  delirium  and  often  contributes  to  the  comfort  of 
the  patient  by  lessening. the  headaches  and  the  many 
morbid  cephalalgic  sensations.  Ice  applications  to  the 
spine  have  been  highly  recommended  by  Gowers  and 
Crichton -Brown.  Bourneville  recommends  ammonia 
inhalations  for  the  convulsions ;  large  doses  of  bromids 
(from  twelve  to  sixteen  grams  daily)  and  camphor. 
The  efficacy  of  this  treatment  rests  entirely  upon  the 
bromid.  The  administration  of  camphor  and  ammo- 
nia inhalations  are  generally  attended  by  negative 
results.  The  subcutaneous  use  of  bromids  in  status 
is  to  be  highly  commended.  After  extensive  trials 
ranging  from  a  10  per  cent,  solution  to  that  of  full 
saturation  of  the  salt,  I  have  determined  that  sub- 
cutaneous injections  of  bromids  should  not  be  given 
in  a  stronger  solution  than  10  per  cent. ;  even  then  in 
about  a  third  of  all  cases  abscesses  will  form;  care 
must  therefore  be  exercised  to  give  the  salt  under 
strict  antisepsis,  and  in  parts  where  abscesses  can  be 
most  easily  treated  in  convalescence.  The  injections 
are  extremely  painful  and  should  be  given  only  when 
coma  is  profound  and  only  when  the  convulsive  stage 
is  well  advanced.  Gentle  friction  and  moist  heat  at 
points  of  bromid  injection  favors  absorption  and  dis- 
courages abscess  and  necrosis.  This  plan  of  giving 
bromids  is  also  recommended  especially  by  Wilder- 


212  STATUS    EPILEPTICUS. 

muth,  and  it  has  been  favorably  commented  upon  by 
many  others.  If  hypodermic  medication  of  bromid  is 
to  be  of  service,  120  grains  should  modify  the  status 
symptoms  in  the  course  of  two  or  three  hours.  If  this 
amount  does  not  appreciably  affect  the  convulsions, 
no  more  salt  should  be  given  by  this  method ;  sodium 
bromid  is  the  best  salt  to  administer  in  this  way. 

Asafetida,  belladonna,  bromethyl,  and  atropin  have 
been  used  by  Bourneville  without  gaining  any  good 
results.  Belladonna,  although  of  signal  value  in 
epilepsy  proper,  has  too  feeble  antispasmodic  proper- 
ties to  be  of  any  great  service  in  status.  Bromethyl 
is  sometimes  effective,  especially  in  incipient  status. . 
Atropin  should  be  used  only  in  respiratory  failure  in 
the  stuporous  stage.  Crichton-Brown  introduced 
amyl  nitrate  and  based  its  favorable  action  in  the 
status  of  epilepsy  upon  the  fact  that  many  of  the 
status  symptoms  were  due  to  the  asphyxia  of  the 
brain  and  that  the  use  of  this  drug  should  relax  the 
arterioles  and  favor  the  circulatory  return.  However 
true  the  theory  may  be,  I  have  never  seen  any  benefit 
by  its  administration  in  the  severe  grand  mat  status, 
but  have  observed  slight  benefits  from  its  use  in  serial 
psychic  epilepsy,  its  action  here  being  due  to  an 
alteration  in  the  cerebral  circulation  from  increased 
cardiac  activity  and  dilation  of  the  arterioles.  The 
increased  blood-supply  in  turn  excites  increased  in- 
hibitory control  of  the  sensory  cortical  cells.  On  the 
other  hand,  cardiac  depressants  and  vasoconstrictors, 
such  as  ergot,  may  have  a  similar  action.  Negative 
and  positive  states  of  cerebral  dynamics  may  give  rise 
to  an  equal  amount  of  cerebral  inhibition.  These 
alternating  sensory  states  due  to  the  modification  of 
the  circulation  are  well  known  to  modify  the  milder 
forms  of  epileptic  paroxysms.  Since  Crichton-Brown's 
advocacy  of  nitrate  of  amyl  in  status,  McBride,  Berger, 


STATUS    EPILEPTICUS.  213 

Jolly,   and   Bourneville  have  advised  against  its  use 
in  status  epilepticus. 

Solwith  has  injected  Bonjeon's  ergotin  in  several 
of  his  patients  with  benefit,  but  Crichton-Brown  and 
a  number  of  others  have  reported  against  its  use.  At 
best,  ergotin  is  but  a  feeble  spinal  depressant  (Word), 
and  on  rational  grounds  the  status  cannot  be  bene-, 
ficially  modified  by  the  drug.  Binswanger  has  recom- 
mended narcotics  on  rational  grounds,  while  Crichton- 
Brown  regards  them  as  pernicious.  Combined  with 
other  drugs,  such  as  the  bromids,  they  are  of  distinct 
advantage.  I  have  employed  them  in  the  convulsive 
stage  of  several  status  cases  with  marked  benefit. 

In  the  past  few  years  amyl  hydrate  has  been  success- 
fully used  by  Wildermuth  in  six  cases.  While  this 
drug  is  uncertain  in  its  therapeutic  properties,  yet  it 
has  no  marked  depressive  action  upon  circulation  or 
respiration  and  may  be  tried  in  the  convulsive  stage 
of  status.  The  following  list  of  drugs  not  before  men- 
tioned in  this  section  have  all  been  tried  and  each  one 
has  its  special  advocate:  Ether,  chloroform,  chloral 
hydrate,  sulphate  of  morphin,  hydrobromate  of  hyos- 
cin,  salicylate  of  physostigma,  and  hydrobromate  of 
cocain.  Ether  and  chloroform  are  given  with  a  view 
of  immediately  checking  convulsions  by  paralyzing 
motor  centers.  They  are  only  of  temporary  value, 
the  better  one  by  far  being  chloroform.  Its  inhalation 
should  be  undertaken  in  the  early  part  of  status,  as  it 
is  too  depressing  upon  the  heart  when  there  is  much 
exhaustion  from  a  large  number  of  attacks.  Ether 
maybe  administered  in  prolonged  status,  as  it  is  devoid 
of  severe  depression  on  the  circulation  and  respiration. 
The  attacks  only  disappear  in  the  use  of  either  when 
given  to  the  point  of  surgical  anesthesia,  and  the 
seizures  return  before  consciousness  is  regained.  As 
heretofore  stated,  anesthetics  should  never  be  em- 
ployed except  when  death  is  imminent  in  convulsions, 


214  STATUS    EPILEPTICUS. 

or  until  slower  drugs,  such  as  chloral  hydrate  and 
bromids,  may  be  taken  in  the  general  circulation. 
When  it  is  injudicious  to  employ  anesthetics  to  the 
surgical  point,  they  may  still  be  used  to  modify  the 
severity  of  paroxysms,  especially  in  Jacksonian  seiz- 
ures, or  in  status  unilateralis  following  organic  brain 
disease. 

The  use  of  chloral  in  status  has  many  advocates  and 
deservedly  so,  but  when  it  is  given  in  advanced  status 
in  from  sixty-  to  ninety-grain  doses  uncombined  with 
other  drugs,  it  is  of  doubtful  value.  Large  doses  of 
chloral  uncombined  with  cardiac  stimulants  should 
always  be  given  with  extreme  caution  in  advanced 
status.  Forty  grains  of  potassium  bromid  and  thirty 
grains  of  chloral  by  rectum,  to  be  repeated  in  three 
hours,  if  convulsion  continues,  is  one  of  the  routine 
treatments  which  I  have  employed.  Chloral  must  be 
given  early  and  before  cardiac  failure  is  imminent. 
At  the  first  indication  that  the  sedatives  are  becoming 
effective  in  controlling  the  convulsions,  the  dose  of 
the  drugs  should  be  modified  accordingly.  Hypoder- 
mics of  a  quarter  of  a  grain  of  morphin  combined  with 
the  foregoing  sedatives  is  often  desirable,  but  the 
action  of  morphin  given  alone  is  too  uncertain  to  be 
of  signal  value.  If  the  convulsions  produce  great 
asphyxia  and  cyanosis,  inhalations  of  oxygen  may  be 
given  with  advantage;  it  aids  the  circulation,  respira- 
tion, and  urinary  secretion. 

A  10  per  cent,  solution  of  bromin  in  an  emulsion 
with  the  oil  of  sesame  is  an  excellent  sedative  for  the 
status,  given  by  rectum  or  hypodermically,  but  to 
be  effective  in  severe  status  it  must  be  given  in  large 
amounts.  Its  sedative  action  is  about  half  of  that 
of  the  bromid  salt,  volume  for  volume.  The  after- 
toxicity  from  the  bromin  sedation  is  much  less  than 
from  the  bromids,  but  bromin  is  much  slower  in  action 
than  the  bromid  salts  and,  as  I  have  already  pointed 


STATUS    EPILEPTICUS.  21  5 

out,  the  early  sedation  in  the  convulsive  stage  is  of 
paramount  importance. 

Chloretone  has  been  used  in  status  to  some  extent 
in  place  of  chloral,  as  the  latter  is  very  dangerous  on 
weak  hearts.  However,  chloral  is  largely  efficacious 
in  status  because  of  its  marked  sedation  on  the  cerebral 
circulation  as  well  as  on  the  brain  itself.  Chloretone 
not  having  this  sedative  power  over  the  circulation,  is 
much  less  valuable  than  chloral;  besides  it  produces 
on  its  own  account,  in  comparatively  small  doses,  a 
toxicity  and  a  resultant  delirium  most  pernicious. 
Chloretone  cannot  supplant  chloral  in  the  treatment 
of  the  status  epilepticus. 

Innumerable  other  remedies  for  a  time  have  had 
their  place  in  status  treatment,  but  they  never  have 
seriously  endangered  the  high  regard  in  which  chloral 
and  bromid  have  been  held.  Status  epilepticus  is  a 
state  above  all  others  in  which  weak  and  ineffectual 
compounds  must  be  cast  aside,  as  the  time  element  in 
gaining  control  of  the  patient's  disease  is  of  paramount 
importance.  Chloral  ranks  first  just  as  pre-eminently 
in  the  treatment  of  the  convulsive  stage  of  status  as 
bromid  does  in  the  medication  of  epilepsy  proper. 

To  summarize  our  plan  for  the  treatment  of  the 
convulsive  stage:  The  "emergency  prescription" 
should  be  administered  after  the  first  six  attacks, 
either  by  mouth  or  by  rectum;  later,  if  status  con- 
tinues, use  chloroform  and  continue  bromid  and 
chloral  by  rectum,  or  hypodermics  of  bromid.  Only 
so  much  sedation  must  be  employed  as  may  be  necessary 
to  control  the  severity  and  number  of  convulsions. 

The  treatment  of  the  stuporous  stage  of  status 
largely  depends  upon  the  severity  and  proper  treat- 
ment of  the  convulsive  stage.  The  treatment  must  be 
supportive.  The  heart  and  lungs  need  close  attention, 
not  only  for  the  acute  exhaustion  entailed  by  the  pre- 
vious convulsive  period,   but  for  complications  that 


2l6  STATUS    EPILEPTICUS. 

are  apt  to  occur  in  the  lungs.  Alcohol  should  be  used 
freely  during  the  exhaustive  state  of  coma.  Although 
the  cold  bath  will  favorably  alter  the  fever  curve  for 
a  time,  its  action  is  rarely  of  lasting  value.  Undoubt- 
edly the  prolonged  action  of  the  sedatives  given  in  the 
convulsive  state  is  in  no  small  degree  responsible  for 
the  severity  of  the  coma;  therefore,  as  a  rule,  drugs 
counteracting  the  antispasmodics  should  be  given  in 
the  stuporous  stage.  The  effects  of  chloral  are  quite 
easily  overcome  by  whisky,  digitalis,  and  strychnin, 
but  the  slower  and  more  permanent  sedation  of  bromid 
is  not  so  easily  counteracted.  As  soon  as  the  ex- 
haustion of  intestinal  peristalsis  is  recovered  from 
sufficiently,  diuretics  and  cathartics  may  be  given. 
The  arterial  pressure  which  is  always  much  lowered 
in  the  stuporous  stage  should  always  be  increased  by 
hypodermoclysis  or  enteroclysis,  as  a  routine  plan  of 
treatment.  When  Cheyne-Stokes  respiration  is  ex- 
treme, faradization  of  the  phrenic  nerve  as  advised 
by  Wildermuth  may  be  tried. 

To  summarize  the  treatment  of  the  comatose  period : 
Counteract  the  exhaustion  and  sedation  of  the  con- 
vulsive stage  and  watch  for  a  possible  return  of  con- 
vulsions ;  in  the  later  stages,  stimulate  and  support  the 
patient  and  treat  complications  promptly. 

The  treatment  of  the  post-status  period  is  generally 
supportive.  Usually  there  is  a  freedom  from  attacks 
for  a  more  or  less  longer  period  of  time,  but  this  is  too 
uncertain  to  warrant  an  entire  withdrawal  of  sedation. 
Occasionally  the  convulsion  may  return  in  the  post- 
status  period  and  cause  death,  as  the  weakened  con- 
dition of  the  organism  is  unable  to  withstand  the 
renewed  onset.  For  the  delirium  and  the  milder  type 
of  mania  in  the  post-status  stage  -^  of  a  grain  of 
hyoscin  combined  with  ^  of  a  grain  of  morphin  may 
be  given.  It  should  be  given  often  enough  to  keep 
the  patient  quiet  and  free  from  the  motor  restlessness 


STATUS    EPILEPTICUS.  21  7 

which  so  frequently  prolongs  and  delays  convalescence. 
Insomnia  is  commonly  a  troublesome  symptom  in  the 
post-status  period ;  it  is  best  controlled  by  small  doses 
of  morphin  combined  with  paraldehyd,  trional,  or 
chloretone.  Hot  baths  and  hot  milk  at  night  are 
often  sufficient  to  overcome  mild  states  of  insomnia. 
Too  little  stress  has  been  placed  upon  the  milder 
remedies  in  restoring  normal  sleep,  and  especially  is 
this  true  in  the  insomnia  after  status ;  its  rule  of  treat- 
ment should  be  largely  comprised  in  rest  and  food. 
The  post-status  mania  rarely  necessitates  treatment 
by  physical  restraint.  But  such  agents,  if  necessary, 
are  best  employed  at  the  patient's  home;  mental 
aberration  is  almost  always  transient.  Epileptics  who 
may  be  insane  in  inter-status  periods  need  to  be 
watched  carefully  after  status,  as  they  are  frequently 
suicidal  and  occasionally  homicidal.  If  the  patients 
do  not  exhibit  great  violence  at  the  inception  of  the 
convulsive  stage,  no  special  change  in  the  surroundings 
of  the  patient  need  be  made;  but  if  the  contrary  ob- 
tains, the  patient's  mattress  should  be  placed  on  the 
floor  in  such  a  manner  that  other  mattresses  may  be 
used  for  side  pads  to  break  the  furious  onset  of  con- 
vulsions. No  epileptic  should  be  physically  restrained 
in  the  convulsive  state,  as  it  only  excites  and  exhausts. 
A  roll  of  cloth  should  be  employed  to  prevent  the 
incessant  biting  of  the  lips  and  tongue. 

The  general  care  and  nursing  of  a  status  case  is  fully 
as  important  as  the  medicinal.  The  temperature  and 
pulse  should  be  recorded  hourly  to  gauge  the  degree 
of  individual  exhaustion  occasioned  by  isolated  attacks. 
The  nurse  needs  to  make  note  of  the  convulsive  phe- 
nomena ;  order  of  muscular  invasion,  if  any ;  length  of 
time  of  tonic  and  clonic  spasm;  the  presence  and 
absence  of  the  typical  symptoms  of  grand  mal,  etc., 
as  the  treatment  is  always  based  upon  the  bedside 
data.     The  kind  and  intensity  of  convulsive  phenom- 


2l8  STATUS    EPILPETICUS. 

ena  are  only  to  be  actually  determined  by  grasping 
the  muscle  involved  in  different  stages  of  an  attack; 
the  eye  is  always  deceptive,  and  many  reported  atyp- 
ical phenomena  of  the  status  have  their  basis  in  the 
latter  form  of  faulty  observation. 

The  administration  of  proper  and  sufficient  food  in  a 
status  case  has  been  found  to  materially  aid  in  saving 
the  patient's  life.  Foods  should  be  in  liquid  form  and 
highly  nutritious  from  the  start.  Various  preparations 
of  milk,  eggs,  and  beef  extracts  may  be  given;  but 
plain  peptonized  milk  is  by  far  the  best  food  of  all. 
It  should  be  given  often  and  in  small  amounts.  All 
foods  should  be  given  early,  before  exhaustion  and 
coma  are  profound.  The  earlier  the  food  is  given,  the 
greater  the  chances  are  that  its  absorption  will  be 
consummated.  As  heretofore  stated,  pharyngeal  and 
laryngeal  paralysis  is  present  in  some  degree  even 
before  coma  is  continuous  between  paroxysms,  there- 
fore many  terminal  bronchi tes,  lobular  and  lobar  pneu- 
monias are  avoided  by  judicious  feeding.  Every 
attention  should  be  directed  toward  preventing  the 
inhalation  of  food  or  vomited  matter  from  forced 
feeding.  As  the  difficulty  of  swallowing  becomes  pro- 
gressively more  marked,  forced  feeding  by  a  nasal  or 
mouth  tube  may  be  resorted  to.  Occasional  lavage  of 
the  stomach  may  be  practised  before  the  feedings. 
However,  on  the  whole,  the  great  distress  to  the  patient 
and  the  liability  to  interruption  by  seizures  render 
the  routine  practice  of  forced  feeding  of  doubtful  value ; 
I  cannot  recommend  it.  As  a  last  resort,  nutrient 
enemata  may  be  given  by  rectum.  The  patient  absorbs 
an  infinitesimal  amount  of  nourishment  taken  by  the 
rectum  in  status,  as  secretive  and  absorptive  activity 
are  at  a  minimum.  Postmortem  in  status  cases  usu- 
ally discloses  a  quantity  of  undigested  food  through- 
out the  intestinal  tract.  The  little  possibility  that 
remains  for  rectal  absorption  should  be  taken  advan- 


STATUS    EPILEPTICUS.  219 

tage  of  for  rectal  medication  and  enteroclysis.  The 
patient  should  be  given  plenty  of  water,  a  fact  fre- 
quently overlooked  in  the  confusion  of  treatment; 
often  the  first  conscious  demand  of  the  patient  is  for 
water. 

BIBLIOGRAPHY  OF  STATUS. 

Alexander,   J.   W.:  "Status   Epilepticus;  Remarkable  Number  of  Fits; 

Recovery."     "Lancet,"  1895,  No.  3757. 
Achermann:  "Das  Amylenhydrat  im  Status  epilepticus."     "Zeitsch.  f.  d. 

Behandlung  Schwachsinniger  und  Epileptiker,"  1896,  XII. 
Bourneville:  "Recherches    sur    l'epilepsie,"    etc.     Published    annually. 

"Case  of  etat  de  mal,  in  1892  and  1897." 

"Progres  med.,"  1887,  No.  35. 

"Arch,  de  neurol.,"  1887,  xin. 

"De  la  thermometric  dans  les  maladies  cer6brales."     "These  de 

Paris,"  1870. 

"Etudes  cliniques  et  thermometriques  sur  les  maladies  du  systeme 

nerveux,"  Paris,  1872,  1876. 

"Recherches  cliniques  et  therapeutiques  sur  l'epilepsie  et  l'hysterie," 


"Progres  med.,"  1878,  No.  8. 

"Bull.  Soc.  Anat.,"  Paris,  1869. 

"Gaz.  med.  de  Paris,"  1874. 

"Compt.  rend.  Soc.  de  Biol.,"  1874. 

"Mouvement  med.,"  1872. 

"Deux    nouveaux    cas    d'etat    de    mal    epileptique."     "Progres 

med.,"  1899,  ix,  161. 

Browne,  Crichton:  "West  Riding  Lunatic  Asylum  Medical  Reports," 
1873,  Vol.  in. 

"Journal  of  Medical  Science,"  April,  1873. 

Beau:  "Arch.  gen.  de  me"d.,"  1836,  Vol.  xi. 
Berger:  "Deutsche  Zeitsch.  f.  prak.  Med.,"  1874. 
Binswanger:  "Eulenberg's  Realencyclopadie,"  1886,  Vol.  VI. 

"Ueber  Epilepsia  vasomotoria."     "Berl.  klin.  Woch.,"  1878,  No. 

27. 

Coggin:  "Boston  Med.  and  Surg.  Journal,"  1874,  Vol.  1. 

Clark  and  Protjt:  "Status  Epilepticus:  A  Clinical  and  Path.  Study  of 

Epilepsy."     "Proceedings  N.  Y.  Neurological  Soc,"  Oct.,  1900;  and 

"Amer.  J.  of  Insanity,"  Oct.  1,  1903. 
Delasiauve:  "Traite  de  l'epilepsie,"  1864. 
Edes,    Robert    T.:  "Status    Epilepticus."     "Virginia    Med.    Monthly," 

1891-92. 
Etjlenberg:  "Lehrb.  d.  Nervenkrankheiten,"  2te  Aufl.,  1878,  Bd.  II. 
Gowers:  "Epilepsy  and  Other  Chronic   Convulsive  Diseases,"   London, 


2  20  STATUS    EPILEPTICUS. 

Hertz:  "Ueber  den  Status  Epilepticus."     "Inaug.-Diss.,"  Strassburg,  1877. 

Hondo:  "Cheugai  Iji  Shinpo,  Tokio."     xvn,  1-9. 

Heroguelle:  "Contribution   a   l'etude    du    traitement   de   l'6tat   de   mal 

epileptique."     "These  de  Paris,"  1895. 
Honig:  "Zur  Therapie  der  Eclampsie  und  Status  Epilepticus."     "Ungar. 

med.  Presse,"  1899,  iv,  7. 
Kuhn:  "Berl.  klin.  Woch.,"  1890,  No.  15. 
Kazowsky:  "Zur  Kenntniss  der  anatomischen  Veranderungen  des  Status 

Epilepticus."     "Ctbl.  f.  Pathologie,"  etc.,  1897,  vxn,  I. 
Kingdom:  "Diagnosis    of    Hystero-epilepsy    from    Status    Epilepticus." 

"Lancet,"  1898,  11,  320. 
Legrand  du  Saulle:  "Gaz.  d.  Hop.,"  1885,  No.  78. 
LEROY,'De  l'etat  de  mal  epileptique."     "These  de  Paris,"  1880. 
Lorenz:  "Inaugural  Dissertation  at  Kiel,"  1890. 
Lewis:  "Med.  Times  and  Gaz.,"  1876. 

McBride:  "Journal  of  Mental  and  Nervous  Diseases,"  1875. 
Maewske:  "Le  cerveau  d'un  epileptique  mort  a  l'etat  epileptique."  "Revue 

neurol.,"  1898,  vi,  No.  II. 
Obersteiner:  "Wien.  med.  Wochenschrift,"  1873,  No.  23. 
Rearson:  "Successful   Treatment   of    Status    Epilepticus    by    Bleeding." 

"Lancet,"  1894,  n,  1489. 
Russell  Reynolds:  "Epilepsie." 

Robinson,  O.  L.:  "Note  on  the  Use  of  Amyl  Nitrite  in  the  Status  Epilepti- 
cus."    "Lancet,"  Oct.,  1896. 
Rispal  et  Anglade:  "Etat  des  cellules  nerveuses  chez  un  epileptique  mort 

en  etat  du  mal."     "Revue  neurol.,"  1898,  vi,  589. 
Smith,  W.  R.:  "Death  in  the  Status  Epilepticus." 
Samt:  "Arch.  f.  Psychiatrie,"  1876,  Bd.  vi. 
Siemens:  "Neurol.   Centralbl.,"   1887. 
Snell:  "Allg.  Zeitsch.  f.  Psychiatrie,"  1875,  Bd.  xxxn. 
Solbrig:  "Allg.  Zeitsch.  f.  Psychiatrie,"  1867,  xxrv. 
Sommer:   "Arch.  f.  Psychiatrie,"  1880,  Bd.  X. 

Satnsbury:   "Journal  of  Mental  Science,"  London,  1889,  xxxv   379 
Trowbridge:   "Status  Epilepticus."     "Journal   of  Mental  and  Nervous 

Diseases,"  1881  (18). 
Tissot:  "Traite  des  nerfs,"  Paris,  1778,  t.  in,  part  1. 
Westphal:   "Arch.  f.  Psychiatrie,"  1868-9,  Bd-  *• 
Wildermuth:  "Neurol.  Centralbl,"  1889. 
Witkowski:   "Berl.  khn.  Woch.,"  1886,  Nos.  43,  44. 
Weber:  "Wien.  med.  Woch.,"  1899,  xlix,  158. 
Zlnsmeister:  "Wien.  med.  Woch.  "  18S5,  Nos.  37,  38. 


CHAPTER  VIII. 
FORMS  OF  EPILEPTIC  AURA.* 

Their  Meaning  and  Significance.  Their  Classification.  Sensory.  Psychic. 
Motor.  Irregular.  Special  Sense  Aura.  Illustrations  of  Each.  The 
More  Common  Forms  and  Types. 

Meaning  and  Significance. — In  its  literal  meaning  the 
word  aura  signifies  "vapor  or  emanation  from  a  body, 
surrounding  it  like  an  atmosphere";  though  in  the 
sense  in  which  it  is  used  to  denote  a  warning  or  a 
symptom  of  an  approaching  attack,  it  has  come  through 
usage  to  have  a  much  broader  clinical  application.  It 
was  first  used  by  Pelops,  the  master  of  Galen,  who 
thought  that  the  fit  began  in  the  form  of  a  "  spirituous 
vapor"  in  the  veins  of  the  extremities  and  ascended 
to  the  head,  whereupon  the  patient  became  uncon- 
scious. 

Much  obscurity  still  surrounds  the  nature  and  value 
of  the  aura  epileptica;  and  while  its  interest  is  great, 
its  practical  value  is  at  present  unfortunately  too 
often  limited  to  aid  in  the  detection  of  the  approach 
of  attacks  which  might  otherwise  be  unperceived  until 
the  convulsion  was  actually  in  progress.  Future 
enlightenment  may  give  them  an  etiologic  value  they 
are  not  now  known  to  possess. 

For  a  long  time  it  was  held  that  the  nervous  impulse 
or  irritation  causing  the  spasm  began  in  the  part 
where  the  aura  first  occurred,  though  now  it  is  generally 
held  that  in  the  vast  majority  of  cases  the  initial 
impulse   begins   in   the   central   nervous   system,   the 

*  From  an  etymologic  ppint  it  would  be  more  correct  to  use  the  classical 
plural,  either  the  Latin  Auras  or  the  Greek  Aurai;  but  aura  has  secured 
so  firm  a  footing  in  medical  English  that  it  seems  useless  to  employ  any 
other  term. 

221 


222  FORMS    OF    EPILEPTIC    AURA. 

sensation  being  referred  only  to  the  periphery.  At  the 
same  time,  there  may  be  an  occasional  case  in  which 
the  impulse  starts  at  the  periphery,  as  has  been  shown 
by  the  cessation  of  the  attacks  when  the  local  irrita- 
tion, such  as  adherent  prepuce  or  a  stricture  of  the 
urethra,  was  removed;  or,  again,  when  the  tying  of  a 
cord  tightly  about  the  member  affected  checks  the 
progress  of  the  fit.  But  in  all  such  cases  the  question 
arises  whether  we  ought  to  designate  the  attacks  as 
epileptic,  or  simply  as  reflex,  or  epileptiform. 

It  is  well  known  that  disease  of  the  brain  may  cause 
descending  degeneration  in  the  spinal  cord,  and 
ascending  disease  in  the  spinal  cord  may  produce 
disease  of  the  brain.  Experiments  have  proved  that 
any  injury  in  the  periphery  may  not  only  cause  changes 
in  the  central  nervous  system,  but  structural  alterations 
in  nervous  tissue  and  functions  in  other  parts  of  the 
periphery  as  well. 

Brown-Sequard  showed  this  to  be  true  when  he  cut 
the  sciatic  nerve  in  the  leg  of  a  guinea-pig  and  caused 
structural  alteration  in  the  skin  of  the  face,  afterward 
producing  epileptiform  convulsions  by  irritating  cer- 
tain portions  of  the  face,  then  removing  the  basis  of 
the  attacks  by  excising  this  epileptogenous  area. 

We  may  also  mention  in  this  connection  the  referred 
sensations  in  coxalgia  in  which  the  pain  is  sharply 
felt  in  the  knee  and  ankle-joint,  and  the  acute  gastric 
pains  that  follow  vertebral  disease. 

There  has  been  a  growing  tendency  for  some  years 
to  regard  the  aura  as  constituting  an  essential  part  of 
the  epileptic  attack.  This  seems  entirely  reasonable, 
fully  as  much  so  as  it  is  to  regard  fever  and  congestion 
as  preliminary  parts  of  pneumonia,  when  pneumonia 
follows.  Sometimes  the  aura  arises  and  persists  for 
an  indefinite  period  and  disappears  without  an  attack 
following;  just  as  there  may  be  fever  and  congestion 
of   the   lungs   without   pneumonia   following.     It   is, 


FORMS    OF    EPILEPTIC   AURA.  223 

therefore,  in  our  opinion,  a  good  plan  to  look  upon 
the  aura  as  the  beginning  of  the  fit,  not  simply  as  a 
warning  of  its  approach,  and  to  treat  the  case  ac- 
cordingly. 

Unfortunately,  this  cannot  often  be  done,  for  it  is 
rare  for  the  physician  to  see  the  patient  before  the 
convulsion  has  occurred,  the  aura  being  not  far  re- 
moved from  the  attack  itself,  generally  not  more  than 
a  few  seconds,  occasionally  half  an  hour  or  so,  while 
in  very  exceptional  instances  the  period  is  longer. 

Classification. — We  can  best  study  the  various  aura 
by  grouping  them  under  four  heads,  as  follows : 

Sensory. 

Psychic. 

Motor. 

Irregular. 
The  first  includes  some  disturbance  in  the  patient's 
sensation;  the  second,  some  disturbance  in  mentality; 
the  third,  some  disturbance  in  the  motor  system; 
while  the  fourth  embraces  elements  of  two  or  more,  or 
even  of  all  of  these. 

It  is  difficult  to  say  which  of  these  forms  of  aura 
possess  the  greater  clinical  importance,  though,  because 
they  so  greatly  outnumber  all  the  rest,  we  incline  to 
attach  the  greatest  weight  to  those  of  a  sensory  nature ; 
those  in  which  a  feeling  of  some  kind,  a  numbness,  or 
tingling,  or  pain,  or  a  feeling  of  discomfort,  is  felt  for 
variable  periods  before  the  fit  comes  on. 

In  a  close  analysis  of  815  men  and  510  women  for 
the  establishment  of  individual  aura,  it  was  found  that 
319  men,  equal  to  36-3-  per  cent,  of  the  entire  number, 
and  186  women,  equal  to  36^  per  cent,  of  the  entire 
number,  had  a  sensory  aura  of  some  kind.  It  is  worth 
noting  how  remarkably  even  this  form  of  aura  ran 
parallel  in  the  two  sexes. 

In  the  same  cases,  33  men  and  19  women  had  psychic 
aura,  the  52  cases  in  both  sexes  constituting  less  than 


2  24  FORMS    OF    EPILEPTIC    AURA. 

4  per  cent,  of  the  entire  number,  while  22  men  and 
10  women,  32  in  all — a  fraction  over  2  per  cent,  of  the 
total — had  a  motor  aura  of  some  kind.  Combining  all 
who  had  an  aura  of  some  kind,  we  have  a  total  of 
589  out  of  1325,  equal  to  about  45  per  cent.,  leaving 
55  per  cent,  who  had  no  aura. 

It  appears  from  this  that  in  less  than  half  of  all 
cases  there  is  a  specialized  aura,  though  it  is  best  not 
to  regard  this  as  conclusive,  for  it  is  reasonable  to 
suppose  that  some  epileptics  of  low  intelligence  experi- 
ence a  sensory  aura  which  they  are  unable  to  describe. 
Allowing  for  these,  it  is  safe  to  say  that  50  epileptics 
out  of  every  100  have  an  aura  of  some  kind. 

This  proportion  is  much  greater  than  that  men- 
tioned by  Echeverria,  who  states  that  a  perceived 
aura  was  found  in  10  per  cent,  of  the  men  and  n£ 
'per  cent,  of  the  women  in  the  306  cases  studied  by 
him. 

Gowers  classifies  the  aura  under  seven  groups,  in 
substance  as  follows:  "  (a)  Unilateral;  (b)  certain  gen- 
eral aura,  such  as  sensations  in  the  limbs,  tremors, 
faintness,  etc. ;  (c)  aura  referred  to  certain  organs, 
especially  those  supplied  by  the  pneumogastric  nerve, 
most  of  the  visceral  warning  coming  under  this  head ; 
(d)  vertigo  and  allied  sensations ;  (e)  certain  sensations 
in  the  head,  pain,  etc. ;  (/)  psychic  aura,  the  conscious- 
ness of  an  emotion  or  idea;  (g)  special  sense  warnings, 
some  of  these  being  unilateral."  In  1000  cases  he 
found — 

1.  A  unilateral  aura  in  86,  topographically  dis- 
tributed as  follows:  in  the  arm  in  45  cases;  in  the  leg 
in  15;  in  the  face  in  17;  in  the  tongue  in  7 ;  in  the 
rump  in  2. 

2.  Bilateral  general  aura  in  74  cases:  in  the  arms  in 
11;  in  the  legs  in  12;  shivering,  trembling,  nausea, 
and  weakness  in  51. 

3.  Aura  affecting  organs  in  106  cases. 


FORMS    OF    EPILEPTIC    AURA.  225 

4.  Fainting  and  dizzy  aura  in  90  cases. 

5.  Head  aura  in  50  cases. 

6.  Psychic  aura  in  25  cases. 

7.  Aura  of  the  special  senses  in  119  cases. 

A  total  of  600  epileptics  out  of  1000  cases  observed 
by  Gowers  had  an  aura  of  some  kind. 

According  to  Binswanger,  Herpin  found  an  aura  of 
the  sense  organs  in  27  per  cent,  of  all  cases;  while  Ben- 
nett found  an  aura  of  some  kind  in  34.4  per  cent.,  the 
latter  finding  the  aura  relatively  rare  in  major  epilepsy 
and  far  more  frequent  in  the  milder  forms, — a  fact 
verified  by  my  own  experience. 

Voisin  *  and  Fere  f  classify  the  aura  under  four 
heads:  Motor,  sensory,  sensorial,  and  intellectual,  fol- 
lowing that  used  by  Delasiauve,  but  neither  gives  an 
estimate  of  the  proportion  of  each.  Fere  states:  "It 
(the  aura)  is  very  frequent;  O'Connor  has  found  it  in 
78  cases  out  of  100." 

According  to  Fere,  Thorion  claims  that  the  epileptic 
crisis  is  preceded  by  a  greatly  increased  elimination 
of  the  urinary  elements,  a  veritable  discharge;  this 
chemical  aura,  he  thinks,  might  even  enable  one  to 
predict  the  return  of  the  attack. 

Sensory  aura  are  vastly  more  common  than  all  the 
rest  and  partake  of  the  greatest  imaginable  range  in 
character.  They  may  be  confined  to  the  special 
senses,  and  include  variable  degrees  of  perversions  of 
taste,  smell,  sight,  touch,  and  sound.  Any  abnor- 
mality in  the  functions  of  the  special  sense  organs  in 
the  nature  of  an  aura  may  be  fleeting  and  transitory, 
or  may  persist  for  hours  before  the  fit  comes  on. 

Visual  aura  greatly  predominate,  occurring  as  often 
as  those  of  taste,  hearing,  and  smell  combined.  They 
usually  take  the  form  of  flashes  of  light,  the  colors  of 
the   rainbow  passing  in  rapid   succession   across   the 

*  "L'epilepsie,"  1897,  p.  54. 

t  "Epilepsy,"  "Twentieth  Century  Practice  of  Medicine,"  Vol.  X,  p.  593. 

15 


226  FORMS    OF    EPILEPTIC    AURA. 

field  of  vision.  In  other  instances  they  appear  in  the 
nature  of  optical  illusions,  people,  dogs,  cats,  and  wild 
animals  of  various  kinds  being  engrafted  on  the  visual 
field ;  while  it  still  more  rarely  happens  that  temporary 
blindness  immediately  precedes  the  attack  (amaurosis 
epileptica) .  In  some  instances  the  sudden  loss  of  sight 
may  alone  constitute  the  entire  attack,  the  area  of 
the  discharging  lesion  being  so  circumscribed  as  to 
produce  no  other  results.  Many  cases  of  persons  sud- 
denly stricken  blind  doubtless  are  due  to  this  cause. 

The  following  instances  taken  from  the  author's 
cases  are  typical  of  the  more  common  forms  of  visual 
aura: 

"  Flashes  of  light,  then  blackness." 

"An  object  passes  before  the  eyes  from  five  to  ten 
minutes  before  the  attack." 

"  Dark  objects  move  before  the  eyes." 

"  Blurred  vision." 

"Flashes  of  blue  and  red." 

"  Flashes  of  light  of  the  rainbow  colors." 

"At  times  sees  colors." 

"Sees  wavelike  motions  in  the  air  just  before  the 
fit." 

"At  times  have  loss  of  vision." 

"Visual  percepts  of  light." 

"Vapor  before  eyes  and  numbness  in  paralyzed 
hand." 

"  Eyes  get  dim." 

"Visual  aura  at  times — sees  a  policeman." 

"  Partial  blindness." 

"  Sees  black,  then  a  yellow  light." 

"Occasionally  a  visual  aura — sees  stars;  at  other 
times  the  aura  is  epigastric." 

"Sees  some  animal  approaching." 

"Everything  looks  bigger  than  it  ought  to  be  just 
before  the  fit ;  people,  chairs,  and  tables  are  magnified." 

According  to  Sir  William  R.  Gowers,  it  is  not  sur- 


FORMS    OF    EPILEPTIC    AURA.  227 

prising  that  when  central  instability  exists  the  visual 
center  should  often  lead  the  way  in  the  sudden  de- 
rangement of  balance,  for  light  constitutes  the  most 
rapid  form  of  motion  of  which  we  have  any  perception, 
consequently  it  must  be  associated  with  a  correspond- 
ing degree  of  delicacy  in  the  central  stimulus  that 
receives  new  impulses  produced  by  waves  of  light. 

In  addition  to  the  forms  of  visual  aura  in  which 
colors  predominate,  other  sensations  and  conditions 
occasionally  affect  the  eye  just  before  a  fit,  one  of 
these  being  diplopia,  or  double  vision.  A  case  of  this 
kind  was  mentioned  by  Gowers,  in  which  the  diplopia 
was  associated  with  an  aching  in  one  eye  and  an  ap- 
parent magnification  of  objects,  things  appearing 
twice  their  usual  size. 

The  curious  condition  of  objects  seeming  to  in- 
crease or  diminish  in  size  is  seldom  encountered.  This 
phenomenon  when  present  is  explained  by  either  an 
increase  or  diminution  in  the  sensitiveness  of  the 
visual  center,  which  produces  an  effect  on  conscious- 
ness analogous  to  that  produced  by  the  stimulation 
of  a  larger  or  smaller  area  of  the  retina  by  a  larger 
or  smaller  image. 

A  male  epileptic,  twenty-four  years  of  age,  who 
came  under  my  care,  had  this  aura,  objects  about  him 
increasing  greatly  in  size  from  ten  to  twelve  seconds 
before  the  fit  appeared. 

In  a  few  cases  there  is  a  sensation  of  pain  in  the  eye- 
ball, due  probably  to  some  irritation  of  the  fifth  nerve, 
these  cases  generally  having  a  motor  element  in  them, 
such  as  twitchings  of   the  muscles  about  the  eye. 

Gowers  *  reports  a  case  in  which  autopsy  was  per- 
formed, and  in  which  the  fits  were  preceded  by  a  flash 
of  light  or  pain  in  the  eye.  The  autopsy  revealed  the 
presence  of  a  tumor  in  the  occipital  lobe,  which  ex- 
tended as  far  forward  as  the  angular  convolution. 

*  "Epilepsy  and  Other  Convulsive  Diseases,"  p.  79. 


228  FORMS    OF    EPILEPTIC    AURA. 

In  addition  to  all  these,  there  have  been  reported 
cases  of  highly  specialized  visual  sensations  in  the 
form  of  complex  visual  conception,  or  psycho-visual 
aura;  that  is,  a  psychic  aura  crowding  itself  in  upon 
the  patient's  field  of  consciousness  coincident  with  the 
appearance  of  some  distorted  visual  percepts.  For 
instance,  a  woman  always  saw  bright  lights — red, 
green,  and  yellow  at  first;  the  lights  continued,  and 
she  saw  a  girl,  "and  tried  to  get  to  her  to  ask  what 
the  lights  meant,"  and  then  fell  in  a  fit. 

When  one  color  only  is  seen,  it  is  most  apt  to  be 
red  or  blue;  when  a  number  follow,  the  most  promi- 
nent order  of  appearance  of  the  colors  is  red,  blue, 
green,  yellow,  and  occasionally  purple.  This  order  is 
not  in  harmony  with  the  physical  relation  of  colors, 
nor  does  it  correspond  to  the  areas  of  retinal  percep- 
tion, for  red,  which  is  most  often  seen,  has  one  of  the 
smallest  retinal  fields.  On  the  other  hand,  it  does 
correspond  to  a  certain  extent  with  the  degree  of 
visibility  of  colors,  for  Gowers  credits  Cohn  with 
having  observed  that  the  order  in  which  spots  of  color 
one  millimeter  in  size  can  be  seen  in  direct  sunlight 
at  a  certain  distance  is  as  follows:  red,  blue,  green, 
yellow,  and  violet,  which  seems  to  be  very  nearly  the 
order  in  which  they  appear  as  aura  in  epilepsy. 

Occasionally  we  find  auditory  and  visual  auras 
associated,  though  this  combination  is  rare,  while  we 
have  knowledge  of  one  case  in  which  there  was  com- 
plete unilateral  loss  of  hearing  just  before  the  fit. 

Auditory  aura  partake,  as  a  rule,  of  the  nature  of 
the  following  hallucinations : 

"Roaring  and  voices  heard  two  or  three  minutes 
before  the  convulsion  appears." 

"  Roaring  in  the  ears." 

' '  Sound  of  sea  waves  in  the  ear  before  mild  attacks. ' ' 

"  Roaring  and  buzzing  in  the  ears." 


FORMS    OF   EPILEPTIC    AURA.  229 

"  Noises  in  the  head  for  a  brief  period  before  the 
attack." 

"Roaring  followed  by  a  sensation  of  falling." 

Auditory  aura  occur  about  a  fourth  as  frequently  as 
the  visual  and  are  generally  present  in  from  2  per  cent, 
to  3  per  cent,  of  all  cases. 

In  addition  to  the  forms  of  auditory  disturbance 
enumerated  above,  the  patient  may  hear  sudden 
sounds  of  almost  any  nature,  like  the  crash  of  a  heavy 
falling  body,  the  blowing  of  a  whistle,  the  ringing  of 
a  bell;  while  more  rarely  there  may  be  the  sounds  of 
voices  or  of  music  alone. 

L.  Pierce  Clark*  quotes  Sante  de  Sanctis  and  A. 
Christiani  as  reporting  three  cases  in  which  the  patients 
indulged  in  a  variety  of  songs  while  undergoing  mild 
convulsive  movements;  two  of  them  kept  time  to 
imaginary  music  with  rhythmic  movements  of  the 
body,  each  showing  some  clonic  muscular  movements 
in  the  lower  extremities,  while  the  third  sang  a  single 
tune,  accompanying  it  with,  movements  imitating  an 
orchestral  direction. 

The  writer  is  familiar  with  the  cases  of  two  young 
adult  male  epileptics,  one  of  them  the  victim  of  an 
infantile  palsy  affecting  the  right  hand  and  foot,  both 
of  them  subject  to  grand  mat  as  well  as  petit  mal 
attacks,  the  latter  form  not  infrequently  being  an- 
nounced by  a  period  of  involuntary  whistling.  I  had 
occasion  to  witness  this  phenomenon  in  one  of  them 
five  times  in  one  day.  The  first  indication  of  an  attack 
was  a  sudden  cessation  of  all  movement  on  the  part 
of  the  patient ;  he  would  stop  and  stand  still  if  walking, 
assuming  a  confused,  puzzled  expression,  when  he 
would  grunt  quite  audibly  two  or  three  times,  and 
then  whistle  a  bar  from  a  popular  song  of  the  day, 
repeating  it  with  the  next  convulsion  in  the  most 
precise   manner.     He   was  fully  cognizant    afterward 

*  "Medical  News,"  Sept.  i,  1900. 


230  FORMS    OF    EPILEPTIC    AURA. 

of  what  he  had  done,  as  shown  by  the  fact  that  he 
always  turned  to  me  with  the  question,  "Did  you 
notice  that  one  ? ' ' 

On  one  occasion  he  caused  a  bank  cashier,  with 
whom  he  was  dealing  at  the  moment,  much  aston- 
ishment and  concern  by  suddenly  repeating  the 
usual  grunt  two  or  three  times,  then  whistling  a  bar 
from  a  popular  opera  while  arranging  an  important 
financial  transaction.  None  of  these  anomalous  states 
lasted  more  than  from  five  to  seven  seconds.  At 
times  they  appeared  as  epileptic  equivalents,  at  others 
as  forerunners  of  more  pronounced  convulsions. 

I  recall  two  cases  in  which  mild  seizures  were  accom- 
panied with  complete  auditory  deafness,  vision  re- 
maining normal,  so  that  signs  made  to  the  patient  to 
do  certain  things  were  immediately  obeyed,  while 
spoken  commands  were  unnoticed. 

Smell  and  Taste. — -Extraordinary  sensations  in  con- 
nection with  smell  and  taste  are  generally  met  with, 
which  take  the  greatest  possible  range  in  character 
and  are  generally  of  an  unpleasant  nature. 

Gowers  thinks  it  significant  that  flavors  which  are 
perceived  only  through  the  olfactory  nerve  seem  to  be 
associated  with  taste  in  the  central  discharge  which 
causes  the  warning,  the  flavor  in  this  instance  being 
of  a  kind  that  enters  the  posterior  nares,  causing  a 
simultaneous  stimulation  of  the  true  gustatory  nerve. 

Some  epileptics  experience  a  bitter  taste,  like 
quinin,  while  others  have  a  metallic  taste  in  the  mouth 
that  sometimes  persists  for  an  hour  or  more  before  the 
convulsion.  One  patient  complained  of  a  feeling  of 
"numbness  in  the  tongue,"  as  though  that  organ  had 
been  completely  cocainized.  Watson  mentions  an 
epileptic  who  could  abort  an  approaching  attack 
through  voluntarily  biting  his  tongue  quite  severely, 
doubtless  having  first  experienced  an  unusual  sensation 
of  some  kind  in  it. 


FORMS    OF    EPILEPTIC    AURA.  231 

Hughlings-Jackson  *  has  drawn  attention  to  a 
group  of  cases  in  which  there  is  at  the  onset  of  the 
paroxysm  a  crude  sensation  of  smell  or  of  taste, 
accompanied  by  movements  of  chewing,  smacking  of 
the  lips,  and  sometimes  spitting,  all  being  ascribed  to 
disturbances  in  the  cortex.  Some  of  these  are  fore- 
shadowed by  an  epigastric  warning. 

A.  T.  states  that  he  almost  always  has  light  attacks 
following  severe  ones  at  night,  and  following  the  light 
attacks  he  has  a  peculiar  taste  and  sensation  in  the 
mouth  which  he  describes  as  follows:  The  first  is  a 
"sour  taste";  the  second,  similar  to  that  of  "wheat 
bran  in  the  mouth";  the  third,  a  feeling  of  "  stringi- 
ness,"  combined  with  "numbness  in  the  upper  part 
of  the  mouth";  the  fourth,  a  "sickish  sweet  taste" 
sufficient  to  produce  extreme  nausea;  the  fifth,  a 
"filthy  nasty  taste"  which  is  extremely  disagreeable; 
the  sixth  and  last  being  a  feeling  of  "sliminess"  in 
the  mouth.  The  morning  following  the  patient  feels 
"  unusually  well, "  much  more  so  than  during  any  time 
more  distant  from  his  seizures.  These  disorders  of 
taste  may  continue  for  a  day  and  gradually  shade  out 
from  the  sixth  condition  to  that  of  normal  sensation. 
They  have  persisted  for  years,  and  cannot  be  ascribed 
to  stomachic  indigestion. 

According  to  Ferrier,  the  senses  of  taste  and  smell 
are  located  in  the  uncinate  gyrus,  since  reflex  irritations 
of  this  gyrus  in  the  animals  he  experimented  on  pro- 
duced "reflex"  movements  analogous  to  those  just 
mentioned  as  occurring  in  the  human  subject,  prior  to 
or  as  a  concomitant  of  lesser  epileptic  convulsions. 

In  the  case  of  a  male  epileptic  of  forty-seven  years 
the  convulsions,  following  alcoholism,  nearly  always 
had  an  aura  which  he  described  as  "  a  snuff  of  bad 
air";  the  fit  appeared  after  two  or  three  inspirations 
that  were  charged  with  this  disagreeable  odor. 

*  "Lancet,"  Jan.  14,  1899. 


232  FORMS    OF    EPILEPTIC    AURA. 

The  epigastric  aura  is  more  commonly  met  with  than 
all  the  other  sensory  aura  combined,  its  presence 
having  been  noted  in  some  form  in  200  cases,  equal  to 
15  percent,  of  the  1325  studied. 

The  nature  of  this  aura  is  fairly  constant,  for  it 
quite  regularly  appears  in  one  of  three  forms:  The 
first  and  most  common  is  that  of  "a  gnawing,  inde- 
scribable, indefinable  sensation  at  the  pit  of  the  stom- 
ach," which  lasts  anywhere  from  a  few  seconds  up  to, 
but  rarely  beyond,  half  an  hour  before  the  fit  is  estab- 
lished; the  second  is  "a  deep-seated  burning  pain"; 
the  third,  "  a  feeling  of  nausea  which  grows  in  intensity 
and  rises  like  a  choking  sensation  toward  the  head, 
until  the  sensation  reaches  the  throat,  when  conscious- 
ness is  lost";  the  latter  closely  resembles  the  globus 
hystericus . 

The  exact  location  and  cause  of  the  pain  and  uneasi- 
ness in  these  cases  is  entirely  problematic,  but  most 
likely  they  are  due  to  some  disturbance  involving  the 
centric  origin  of  the  vagus  nerve.  This  nerve  has  a 
wider  distribution  than  any  other  of  the  cranial 
nerves,  supplying,  as  we  know,  the  organs  of  voice 
and  respiration  with  both  motor  and  sensory  fibers. 
Its  immediate  communications  are  also  extensive  and 
remote,  while  at  the  seat  of  its  origin  it  has  control 
over  the  two  most  vital  processes  of  life — respiration 
and  circulation. 

The  rhythmic  sequence  of  the  respiratory  movements 
is  apparently  due  to  periodic  discharges  from  the 
respiratory  center  located  in  the  floor  of  the  fourth 
ventricle,  on  each  side  of  the  median  line,  the  two 
halves  being  intimately  connected  by  commissural 
fibers.  The  cause  of  this  periodicity  is  obscure,  but 
since  it  has  been  shown  *  that  the  rhythm  continues 
after  the  combined  section  of  the  vagi  and  glosso- 
pharyngeal nerves,  the  spinal  cord  in  the  lower  cervical 

*  "American  Text-Book  of  Physiology,"  p.  458. 


FORMS    OF    EPILEPTIC    AURA.  233 

region,  the  posterior  roots  of  the  cervical  spinal  nerves, 
and  the  separation  of  the  spinal  bulb  from  the  parts 
above,  it  indicates  that  it  is  inherent  in  the  nerve 
cells  and  is  not  caused  by  external  stimuli  carried  to 
the  center  through  afferent  nerve  fibers. 

Loewy  has  shown  that  under  the  above  circum- 
stances the  rhythm  is  due  to  the  blood  "which,  while 
acting  as  a  continuous  excitant,  causes  discontinuous 
or  periodic  discharges,"  and  since  the  blood-supply  is 
under  nervous  control,  the  respiratory  center  is  auto- 
matic only  with  reference  to  external  nerve  stimulation. 

The  problem  in  epilepsy  that  rests  on  this  point  is 
to  determine  whether  the  initial  disturbance,  the 
influence  that  breaks  up  the  rhythmic  periodicity  of  the 
respiratory  impulse,  is  to  be  sought  in  the  respiratory 
center  primarily,  or  whether  it  lies  somewhere  in  the 
periphery,  in  the  stomach,  in  the  heart,  or  in  the 
circulation,  and  is  carried  by  some  vital  process  to  the 
seat  of  respiratory  life. 

It  is  unusual  for  the  epigastric  aura  to  be  referred 
to  any  other  locality  than  the  immediate  region  of  the 
stomach.  In  one  case  the  pain  first  appeared  in  the 
right  iliac  region,  and  was  always  attended  with  a 
feeling  of  nausea.  It  is  noteworthy  that,  while  the 
vague  sensation  which  nearly  always  accompanies  the 
epigastric  aura  passes  upward  to  the  throat  and  head, 
the  pain  remains  stationary  in  the  region  of  the  stom- 
ach. As  a  rule,  consciousness  is  lost  as  soon  as  the 
aura  reaches  the  head. 

Many  patients  who  exhibit  an  epigastric  aura  suffer 
from  indigestion  which  makes  its  appearance,  to  some 
extent,  periodically ;  other  stomach  disorders  are — dis- 
tention, gastric  catarrh,  and  flatulence. 

It  seems  now  a  problem  as  to  whether  these  condi- 
tions precede  or  follow  the  initial  manifestations  of  the 
fit,  and  on  this  point  I  differ  with  Sir  William  R. 
Gowers,  who  says:  "We  are  not  justified  in  assuming 


234 


FORMS    OF    EPILEPTIC    AURA. 


that  flatulence  is  the  cause  of  the  attack  any  more  than 
we  are  in  regarding  gastric  disturbance  as  the  cause 
of  an  attack  of  migraine  which  subsides  with  vomiting. ' ' 
It  seems  rational  to  hold  that,  while  the  flatulence 
itself  may  not  include  the  attack,  the  conditions  which 
caused  the  flatulence  may  be  to  blame  for  it,  for  the 
reason  that  correction  of  disturbances  in  the  processes 
of  nutrition  often  lessen  or  entirely  remove  the  cause 
of  the  attacks. 

All  this  points  to  the  importance  of  studying  chemic 
pathology  as  a  cause  of  epilepsy — a  vast,  prolific  field 
as  yet  but  little  explored,  and  still  less  understood. 


THE  EPIGASTRIC  AURA  IN  FIFTY  OUT  OF  TWO  HUNDRED 
CASES,    PRESENTED   TO  SHOW  THE   CHIEF  FEA- 
TURES OF  THIS    FORM  OF  WARNING. 


No. 

Age  at  On- 
set of 
Epilepsy. 

Character 
of  Attacks. 

Nature  of  Aura. 

Time  between 
Aura  and 
Attack. 

Frequency  of 
Attacks. 

I 

28  years. 

G.M.-P.M. 

Pain   in  the  upper 
part    of    the    ab- 
domen. 

5  minutes. 

About  2  per  month. 

2 

9      " 

G.M. 

Feeling  of  faintness 
in  the  stomach. 

5 

12  per  month. 

3 

36      " 

G.M. 

Distressed    feeling 
in  the  stomach. 

5 

10    "        " 

4 

1%  " 

G.M.-P.M. 

Faintness     in    the 
stomach,  rising  in 
the     throat,    and 
then     roaring    in 
the  ears. 

2        " 

12     "         " 

5 

24      " 

G.M. 

Something     rising 
from  the  stomach 
to  the  throat,  like 
a  ball  or  lump,  pro- 
ducing a  choking 
sensation. 

V2  minute. 

9      " 

6 

18      " 

G.M.-P.M. 

Pain   in    the  stom- 
ach,      spreading 
over  the  body. 

5  minutes. 

3      " 

7 

17      " 

G.M. 

Pain   in   the  stom- 
ach. 

10      " 

8  to  12  per  month. 

8 

35      " 

G.M. 

Pain   in   the   stom- 
ach, spreading  to 
the  lower  part  of 
the  abdomen. 

1  hour. 

16  to  20    "        " 

9 

11       " 

G.M. 

Burning    sensation 
in  the  stomach. 

1  day. 

2  to  3        "        " 

10 

13      " 

G.M. 

Sensation  of  some- 
thing rising  from 
the  stomach  to  the 
throat  and  head. 

2  minutes. 

7  per  month. 

ii 

4      " 

G.M. 

Burning    sensation 
rising    from     the 
stomach. 

1  to  5  minutes. 

3    " 

12 

20      ". 

G.M. 

Sensation  of   pres- 
sure on  the  stom- 
ach,    passing     to 
the    throat,    pro- 
ducing a  choking 
sensation. 

1  to  2  minutes. 

4    " 

FORMS    OF    EPILEPTIC    AURA. 


235 


No. 

Age  at  On- 
set of 
Epilepsy. 

Character 
of  Attacks. 

Nature  of  Aura. 

Time  between 
Aura  and 
Attack. 

Frequency  of 
Attacks. 

13 

21  years. 

G.M.-P.M. 

Sickness      at      the 
stomach  ;    then   a 
fluttering    feeling 
which  goes  up  to 
the    throat,   caus- 
ing     a     choking 
sensation. 

1  minute. 

8  per  month. 

14 

3      " 

G.M. 

Burning  pain  in  the 
stomach,  rising  to 
the    throat,   then 
to  the  head. 

1         " 

1     "        " 

15 

16      " 

G.M. 

Pain    in   the   stom- 
ach. 

1  hour. 

4     "        " 

16 

13      " 

G.M. 

Sensation  of  some- 
thing rising  from 
the     stomach    to 
the  throat. 

15  seconds. 

10  "         " 

17 

25      " 

G.M.-P.M. 

Sensation     of    gas 
rising    from    the 
stomach,  causing 
oppression  and  a 
smothering     feel- 
ing. 

Y  minute. 

10  "         " 

18 

14      " 

G.M. 

Stomach   feels   full 
of   gas.     Oppres- 
sion    about     the 

heart. 

1  minute. 

4    " 

19 

7      " 

G.M.-P.M. 

Nausea.     Some- 
thing rises  to  the 
throat.    Wants  to 
drink. 

1       '' 

8     " 

20 

20      " 

G.M.-P.M. 

Sensation  of  a  ball 
rising    from    the 
stomach     to     the 
throat,  producing 
a  choking  sensa- 
tion. 

1  to  2  minutes. 

12  "         " 

21 

12      " 

G.M. 

Nausea     and    dis- 
tress in  the  stom- 
ach. 

2  to  3  hours. 

5  to  10  per  year. 

22 

9      " 

G.M. 

Burning  sensations 
in     the    stomach, 
passing  up  to  the 
throat,  producing 
a  choking  sensa- 
tion. 

2  to  5  months. 

20  to  30  per  month. 

23 

12      " 

G.M.-P.M. 

Faintness;   then   a 
sensation     as     if 
something       was 
crawling  from  the 
stomach     to     the 
throat,     with     a 
choking  sensation. 

1  to  2        " 

12 

24 

11       " 

G.M. 

Sensation  of  some- 
thing rising  from 
the    stomach     to 
the  throat. 

Yz  minute. 

9 

25 

3       " 

G.M. 

Indescribable    feel- 
ing beginning   in 
the  abdomen  and 
spreading  upward. 

5  to  10  seconds. 

7  to  10      "        " 

26 

2       " 

G.M. 

Faintness     in     the 
stomach. 

5  to  10 

7  to  10      "        " 

27 

4      " 

G.M.-P.M. 

Sensation    of    full- 
ness in  the  stom- 
ach passing  up  to 
the     throat     and 
mouth. 

5  to  30        " 

10 

28 

4      " 

G.M. 

Burning  feeling  in 
the  stomach,  pass- 
ing to    the   heart 
and     throat,    fol- 
lowed by  a  chok- 
ing sensation. 

1  minute. 

1                "        " 

236 


FORMS    OF    EPILEPTIC    AURA. 


No. 

Age  at  On- 
set of 
Epilepsy. 

Character 
of  Attacks. 

Nature  of  Aura. 

Time  between 

Aura  and 

Attack. 

Frequency  of 
Attacks. 

29 

2  years. 

G.M. 

Pain  in  the  epigas- 
trium,   rising    to 
the     throat     and 
then  to  the  head. 
Sensation  of  a  ball 
in  the  throat. 

2  minutes. 

3  to  10  per  month. 

3° 

23      " 

G.M.-P.M. 

Pain   in   the  stom- 
ach and  a  flutter- 
ing feeling  in  the 
abdomen. 

5 

3  to  10     "        " 

31 

3      " 

G.M. 

Sensation       rising 
from  the  stomach 
to  the  throat. 

%  minute. 

10             "        " 

32 

5      " 

G.M.-P.M. 

Nausea  and   "bad 
feeling"     in     the 
stomach. 

1  minute. 

9              « 

33 

6  weeks. 

G.M. 

Feels       something 
move     from    her 
right  side  to  the 
stomach ;        then 
rises  to  the  throat 
and   head.      Pain 
in  the  stomach. 

1  to  5  minutes. 

6 

34 

7  years. 

G.M. 

Tremor      in      the 
stomach. 

1  to  3  hours. 

12             ''        " 

35 

3      " 

G.M.-P.M. 

Pain   in   the  abdo- 
men, rising  to  the 
head. 

1  minute. 

7 

36 

33       " 

G.M.-P.M. 

Sensation  of  some- 
thing like   a  ball 
rising    from    the 
stomach    to     the 
throat. 

2  minutes. 

7  to  10     "        " 

37 

3       " 

G.M. 

Pain   in   the   stom- 
ach. 

2  to  3  minutes. 

3° 

38 

11       " 

G.M. 

Sharp  pains  in  the 
stomach. 

1  hour. 

1  to  2        "         " 

39 

7  months. 

G.M. 

Pain   in   the    stom- 
ach. 

1  to  2  hours. 

I  tO  2          "            " 

40 

14  years. 

G.M. 

Sensation  of  some- 
thing rising  from 
the  stomach. 

1  to  3  minutes. 

I  to  5        "         " 

41 

13      " 

G.M. 

Bad  feeling  in  the 
stomach,  rising  to 
the  throat. 

1  minute. 

4 

42 

24      " 

G.M. 

Burning  sensation 
rising    from     the 
stomach     to    the 
head,    producing 
a  choking  sensa- 
tion. 

y2  to  1  minute. 

7 

43 

12      " 

G.M.-P.M. 

Nausea    and     ver- 
tigo. 

1  hour. 

1  to  5       " 

44 

Infancy. 

G.M. 

Sick    at   the   stom- 
ach,    and     dizzi- 
ness. 

1    " 

12  to  16    "        " 

45 

33  years. 

G.M.-P.M. 

Sensation  of  some- 
thing rising  from 
the     stomach     to 
the  throat. 

%  minute. 

10 

46 

13      " 

G.M. 

Pain    in   the  stom- 
ach. 

2  minutes. 

12 

47 

5      " 

G.M.-P.M. 

Nausea  ;        then 
something  rising 
from    the     throat 
to  the  head. 

1  to  3  minutes. 

22 

48 

18  months. 

G.M. 

Pain   in  the  stom- 
ach  and  vertigo. 
Sensation  of  some- 
thing    rising     to 
the  throat. 

1  minute. 

2toS           "            " 

49 

11  years. 

G.M. 

Pain    and    fullness 
in  the  stomach. 

1        " 

4 

50 

6      " 

G.M. 

Nausea    and    ver- 
tigo. 

1  hour. 

1 

FORMS    OF    EPILEPTIC    AURA.  237 

Psychic  aura  may  appear  in  the  form  of  a  sudden 
abnormal  mental  state,  leaving  a  definite  impression 
on  the  memory,  due  to  the  fact  that  brain  processes 
which  attend  mental  states  may  leave  a  residual 
effect  which  makes  it  possible  for  their  subsequent 
revival,  the  perception  of  which  we  are  apt  to  refer 
to  as  "psychic  sensations." 

The  most  common  form  assumed  by  the  psychic 
aura  is  the  sudden  acceleration  of  the  imagination;  a 
quick  overflowing  in  the  processes  of  thought,  in  which 
the  train  of  the  imagination,  ever  rapid,  is  rushed 
ahead  with  trembling,  excited  haste,  until  the  thread 
is  snapped  and  unconsciousness  occurs. 

In  some  cases  this  stimulation  of  the  imagination 
may  be  preceded  by  confused  ideation,  with  different 
memory  pictures  appearing  momentarily  in  succession. 

Romberg  mentions  a  young  man  with  epilepsy,  who 
for  nine  years  had  the  same  recurring  thought  which 
was  never  quite  clear  to  him  and  which  caused  him 
great  unrest.  He  endeavored  to  free  himself  from  the 
idea  which  took  the  same  course  every  time,  and  dis- 
appeared with  the  beginning  of  the  attack. 

Binswanger  states  that  "similar  observations  in 
which,  in  each  attack,  definite  memory  pictures 
appeared  in  'glaring  psychic  illuminations'  are  still 
found  in  the  literature." 

When  such  sensations  precede  an  epileptic  fit,  they 
may  also  be  in  the  single  form  of  an  emotion  or  an 
idea,  the  former  generally  being  in  the  form  of  fear, 
an  apprehension  of  something  evil  about  to  occur,  the 
patient  being  genuinely  frightened  and  attempting  to 
run  away.  In  some  of  the  illustrative  seizure  in- 
stances noted  in  the  last  chapter,  it  was  stated  that 
the  patient's  face  wore  "a  terrified  aspect,"  and  that  in 
one  or  two  instances  the  patient  tried  to  run  away 
from  impending  danger  that  seemed  to  him  to  be 
present.     The  presence  of  this  feeling  or  danger  is  also 


238  FORMS    OF    EPILEPTIC    AURA. 

testified  to  by  patients  who  involuntarily  show  fight 
when  interfered  with  while  in  a  seizure,  or  just  as  they 
are  going  into  one. 

I  have  in  mind  numerous  instances  of  this  kind,  one 
of  them  being  a  young  man  subject  to  frequent  attacks 
of  psychic  epilepsy,  during  some  of  which  he  would 
appear  pale,  confused,  and  ill  for  some  time  before 
the  fit,  so  that  he  not  infrequently  got  into  trouble 
in  public  places  by  assaulting  the  persons  who  felt  it 
their  duty  to  care  for  him  when  he  seemed  to  require 
it.  If  let  alone,  he  would  pass  through  the  seizure 
without  harm,  but  the  moment  a  hand  was  laid  on 
him  to  assist  him,  he  became  extremely  violent  and 
would  fight  with  great  vigor  until  overpowered.  He 
was  always  ignorant  of  his  acts  in  this  respect  after 
his  fit  was  over. 

Fear,  of  a  primary,  instinctive,  and  therefore  of  an 
unreasoning  kind,  is  the  type  met  with  in  psychic  aura, 
and  it  springs  from  the  instinct  of  individual  con- 
servation. 

According  to  Th.  Ribot,  in  The  Psychology  of  the 
Emotions,  fear  is  the  first,  in  chronological  order,  of 
the  instincts  to  appear,  showing  itself,  according  to 
Pryer,  at  twenty-three  days,  according  to  Perez  at 
two  months,  and  according  to  Darwin  at  four  months. 

Ribot  then  goes  on  to  speak  of  the  characteristic 
marks  of  fear,  so  far  as  it  affects  the  innervation  of 
the  voluntary  muscles;  of  the  muscles  of  organic  life, 
and  finally  of  the  vasomotor  apparatus,  the  concrete 
results  making  a  very  distinct  picture  of  the  condition 
of  fear. 

The  very  interesting  question  now  arises  as  to  how 
fear  can  be  artificially  induced;  in  other  words,  what 
is  the  process  that  brings  it  into  existence  so  that  it 
stands  for  a  symptom  in  part  of  an  epileptic  convulsion  ? 
If  we  could  answer  this,  we  could  place  at  least  a  part 
of  our  psychologic  studies  on  firmer  ground. 


FORMS    OF    EPILEPTIC    AURA.  239 

The  warnings  which  take  the  form  of  "ideas"  are 
generally  dependent  on  special  sense  conceptions, 
especially  on  vision.  Gowers  mentions  a  woman  who 
saw  London  in  ruins,  the  Thames  emptied  to  receive 
them,  and  herself  the  lonely  survivor.  This  he  calls  a 
manifest  "psycho-sensory  warning." 

All  special  disturbances  such  as  these  have  the  same 
basic  meaning;  they  indicate  some  instability  of  the 
centers  connected  with  the  psychic  processes. 

I  have  referred  to  a  woman  who  had  an  irregular 
aura,  the  first  part  of  which  was  psychic  and  which 
gave  her  a  feeling  of  great  buoyancy  and  exhilaration. 
While  this  is  not  a  common  aura,  it  is  distinct  in  type 
and  of  more  than  passing  interest. 

Binswanger,  in  describing  the  disturbances  of  feeling 
due  to  an  approaching  attack,  states  that  "more 
rarely  we  find  sensations  of  serenity,  placidity,  calm- 
ness, sudden  apparitions  of  joy,  rapture,  colossal  light- 
ness, an  elevating  good  feeling.  Some  patients  declare 
that  in  the  beginning  of  the  attack  they  feel  freed  from 
a  heavy  burden. ' '  This  exactly  portrays  the  emotional 
state  which  the  Russian  novelist  Dostoieffsky,  who 
suffered  from  epilepsy,  applies  to  himself  in  "Besi." 
"There  are  moments,"  he  writes,  "and  it  is  only  a 
matter  of  five  or  six  seconds,  when  you  suddenly  feel 
the  pressure  of  eternal  harmony.  This  phenomena  is 
neither  terrestrial  nor  celestial,  but  is  an  indescribable 
something  which  man  in  his  mortal  body  can  scarcely 
endure.  .  .  .  The  terrible  thing  is  the  frightful  clear- 
ness with  which  it  manifests  itself  and  the  rapture  with 
which  it  fills  you.  During  those  few  seconds  I  live 
a  whole  human  existence." 

Motor  Aura. — It  is  often  difficult  to  distinguish 
motorial  forms  of  aura  from  the  beginning  of  the  con- 
vulsive period  itself.  Indeed,  as  we  have  previously 
stated,  aura  of  all  kinds  might  very  properly  be  looked 
upon  as  the  entering  wedge  of  the  fit  itself,  notwith- 


240  FORMS    OF    EPILEPTIC    AURA. 

standing  that  they  may  at  times  come  and  go  without 
expanding  into  a  convulsion. 

A  man,  twenty-eight  years  of  age,  had  a  persistent 
motor  aura  in  the  form  of  a  jerking  movement  that 
began  in  the  right  arm.  It  was  just  enough  at  first 
to  lift  the  arm  a  few  inches  from  his  lap,  but  grew 
stronger  each  time,  the  jerks  being  two  or  three  seconds 
apart,  until  finally  the  arm  was  raised  at  each  impulse 
straight  above  the  head.  As  soon  as  this  condition 
was  reached,  the  jerking  began  in  the  left  arm,  and 
followed  the  same  course,  until  both  arms  were  finally 
jerked  over  the  head  at  each  impulse,  when  a  general 
convulsion  ensued  involving  the  whole  body,  the 
patient  dropping  unconscious  to  the  floor.  It  required 
at  times  from  half  to  three  quarters  of  an  hour  for 
these  motor  manifestations  to  develop  up  to  the  con- 
vulsive point,  a  sufficient  length  of  time  in  which  to 
administer  a  remedy  that  often  served  to  abort  the 
attack. 

A  common  form  of  motor  aura  is  that  of  running,* 
just  before  the  fit,  the  so-called  procursive  epilepsy. 
Patients  who  exhibit  this  phenomenon  are  rare,  and, 
as  a  rule,  are  apt  to  be  extremely  violent  during  the 
attack.  A  boy  would  start  and  literally  run  like  a 
deer  for  half  a  mile  before  falling  in  an  active  convulsion, 
which  was  always  followed  by  great  exhaustion. 

Another  case  of  the  kind  was  that  of  a  young  married 
woman,  who  seemed  to  possess  superhuman  strength 
from  the  way  she  demolished  the  stoutest  woodwork 
when  in  a  grand  mat  seizure,  and  who  could  not  be 
allowed  out  of  the  hospital  for  a  walk  because,  on  the 
point  of  an  attack,  she  would  run  far  enough  away 
from  the  attendant  to  get  lost. 

When  a  seizure  appeared  while  she  was  in  the  ward 
she  would  run  at  breakneck  speed  its  entire  length — 

*  Running  in  this  instance  is  classed  as  an  aura  because  it  is  a  coordinate 
movement  and  readily  separated  from  the  fit  that  follows. 


FORMS    OF    EPILEPTIC    AURA.  241 

about  120  feet,  jump  up  and  thrust  both  legs  through 
the  window  and  out  through  the  spaces  between  the 
iron  bars,  remaining  in  this  position  until  the  worst 
of  the  convulsion  was  over,  it  being  almost  impossible 
to  tear  her  grip  loose  from  the  iron  bars. 

Gould  and  Pyle  *  mention  "a  peculiar  case  of  epi- 
lepsy, the  patient  being  a  workman  who  would  be 
suddenly  seized  with  a  paroxysm  and  unconsciously 
run  some  distance  at  full  speed.  On  one  occasion  he 
ran  from  Peterboro  to  Whittlessy  (distance  not  stated) , 
when  he  was  stopped  and  brought  back,  while  on 
another  occasion  he  ran  into  a  pit  containing  six  feet 
of  water,  from  which  he  was  rescued." 

Echeverria  f  described  the  case  of  a  girl  twenty-two 
years  old,  who  had  general  convulsions  that  always 
occurred  in  the  daytime,  the  attacks  being  preceded 
by  an  uncontrollable  desire  to  run.  If  held  at  the 
time  and  violently  shaken,  the  paroxysms  would  occa- 
sionally be  cut  short. 

These  "running  fits"  came  on  at  the  age  of  twelve 
years  and  grew  steadily  worse,  until  the  girl's  mind 
was  practically  destroyed.  As  a  remedy,  it  was 
directed  that  "she  try  violent  exercise  at  skipping  the 
rope,  in  addition  to  having  a  seton  in  the  back  of  her 
neck,  and  being  made  to  take  large  doses  of  the  bromid 
of  potassium  and  conium."  The  author  adds  that 
"the  perturbation  caused  by  the  violent  jumping  evi- 
dently proved  of  great  avail.  No  fits  were  repeated 
in  the  course  of  three  weeks  after  beginning  the  above 
treatment  joined  to  a  tonic  regimen." 

The  same  writer  mentions  that  violent  exercise  on 
a  trapeze  controlled  the  spasms  in  another  patient; 
the  patient  resorting  to  the  practice  of  his  own  accord 
in  the  belief  that  bodily  fatigue  would  keep  of!  the 
convulsions. 

*  "Anomalies  and  Curiosities  of  Medicine,"  p.  852. 
t  "Epilepsy,"  p.  257. 
16 


242  FORMS    OF    EPILEPTIC    AURA. 

A  carpenter's  son,  a  young  man  of  twenty-four 
years,  of  powerful  physique,  often  showed  the  first 
evidence  of  an  attack  by  suddenly  springing  into  the 
air,  sometimes  with  such  force  as  to  turn  a  complete 
somersault,  generally  falling  on  the  back  and  head; 
immediately  afterward  clonic  contractions  would  set 
in,  so  violent  as  to  require  five  or  six  strong  men  to 
hold  him  so  that  he  would  not  injure  himself;  but  as 
it  was,  his  body  for  weeks  after  an  attack  was  often 
covered  with  sores,  bruises,  and  scars. 

Other  epileptics  turn  completely  around  one  or  more 
times  before  the  attack  comes  on,  the  direction  of  turn- 
ing being  uniform;  that  is,  if  they  turn  to  the  left  this 
time,  they  will  turn  to  the  left  in  subsequent  attacks. 
Some  walk  backward  a  few  steps,  then  fall  heavily, 
striking  on  the  occiput,  repeating  this  often  enough 
to  keep  an  unhealed  wound  on  the  scalp  at  that  point, 
unless  a  pad  is  worn  to  prevent  it. 

"Trembling  from  head  to  foot,"  as  patients  describe 
it,  is  witnessed  in  some  cases,  conjointly  or  not  with 
an  epigastric  aura.  A  feeling  of  "  giddiness"  just  before 
the  fit  is  comparatively  common. 

Isolated  contractions  of  certain  parts  of  the  body, 
like  the  thumb  or  fingers,  or  the  great  toe,  may  also 
announce  the  coming  of  an  attack. 

A  woman  who  came  under  the  writer's  care  a  few 
years  ago,  began  at  one  o'clock  in  the  night  to  have  a 
series  of  convulsions  that  were  checked  after  the 
eighth  one;  but  recurred  six  hours  later  and  kept 
recurring  for  forty-nine  hours  and  a  half,  until  549 
had  taken  place.  The  initial  spasm  each  time  was  a 
sharp,  clear  contraction  of  the  first  phalanx  of  the 
right  thumb,  as  indicated  in  the  illustrations  (Plate 
7).  After  two  hundred  seizures,  the  patient  went  into 
status  epilepticus,  the  temperature  gradually  rising 
to  10 70.  Death  occurred  at  the  beginning  of  the 
third  day. 


FORMS    OF    EPILEPTIC    AURA.  243 

Irregular  Aura. — It  is  impossible  to  estimate  with 
accuracy  the  frequency  of  irregular  forms  of  aura, 
but  they  are  not  common,  occurring  less  frequently 
than  those  of  a  psychic  nature. 

It  was  illustrated  in  a  woman  who  first  experienced 
a  feeling  of  buoyancy  and  exhilaration  which  later  gave 
way  to  a  highly  emotional  state  that  persisted  for 
several  days,  and  sometimes  even  for  weeks,  before 
an  attack;  while  for  two  or  three  days  before  the 
attacks  a  motor  aura,  in  the  way  of  uncertainty  of 
gait  appeared,  the  patient  stumbling  along  as  though 
half  tipsy,  or  being  unable  to  grasp  or  pick  up  a  small 
object,  such  as  a  button  or  large  needle;  this  grew 
more  pronounced  until  the  fit  was  over,  when  the 
bilateral  paretic  condition  and  unbalanced  emotional 
state  both  completely  disappeared.  The  irregular 
aura  in  this  case  was  composed  of  psychic,  sensory, 
and  motor  elements  each  dominating  in  turn,  though 
being  in  part  present  at  the  same  time. 

Some  have  a  warning  of  an  attack  in  "a  sleepy 
feeling,"  somnolence.  It  is  impossible  for  them  to 
keep  normally  awake.  This  feeling  may  exist  for  a 
day  or  so  before  the  convulsion  appears,  being  exactly 
opposite  to  another  state  in  which  the  patient  feels 
"unusually  bright  and  active,  mentally  and  physic- 
ally," for  some  time  before  the  fit,  to  be  plunged  into 
painful  dejection  after  it  is  over. 

H.  N.  Mover*  reports  the  case  of  a  young  man  of 
good  family  history  and  correct  personal  habits  until 
the  age  of  fifteen,  when  he  became  alcoholic.  At 
nineteen  he  was  nervous,  suffered  from  destructive 
diseases,  and  had  hallucinations  during  his  waking 
hours — seeing  strangely  formed  animals  approach 
him  several  times.  In  1895  he  became  afflicted  with 
a  tendency  to  sleep,  so  that  he  had  frequently  to  lie 
down  several  times  a  day  for  the  purpose — from  twenty 

*  "Medical  Record,"  Nov.  19,  1899. 


244  FORMS    OF    EPILEPTIC    AURA. 

to  fifty  times  the  patient  himself  states — sleeping 
only  a  few  moments  each  time. 

When  running  an  elevator  he  would  sleep  while 
passing  several  floors.  He  had  other  attacks  which 
he  described,  which  differed  from  the  ordinary  sleep- 
ing attacks.  "Once  at  the  table  he  suddenly  became 
unconscious,  the  attack  probably  being  epileptic." 

It  is  difficult  to  say  to  what  extent  these  attacks  of 
somnolence  may  have  been  modified,  psychic,  epileptic 
convulsions.  It  seems  evident  that  toward  the  last 
in  the  case  above  they  were  intimately  associated  with 
ordinary  epilepsy. 

In  rare  instances  the  heart  is  the  seat  of  disturbances 
that  indicate  an  approaching  attack,  some  pain,  but 
more  particularly  a  "feeling  of  distress"  being  felt 
in  the  cardiac  region,  palpitation  being  comparatively 
common. 

When  cephalic  sensations  are  experienced,  they  are 
generally  dependent  upon  the  extension  of  an  aura 
that  had  its  origin  in  some  other  part,  like  the  stomach, 
though  there  is  occasionally  a  sense  of  "fullness," 
or  "a  rushing  sensation"  experienced  in  the  head 
or  throat,  independent  of  any  disturbance  anywhere 
else. 

M.  Allen  Starr,*  in  a  series  of  65  cases  of  epilepsy, 
noted  aura  as  follows:  "Epigastric  sensations  were 
the  most  frequent,  being  present  in  19;  visual  sen- 
sations of  light,  or  sparks  of  blue  or  red  in  14;  tactile 
or  sensory  sensations  in  the  form  of  tingling  or  numb- 
ness in  the  body  or  limbs  in  1  o ;  in  7  the  patients  com- 
plained of  vertigo;  in  8  they  experienced  a  sensation 
of  fear  without  known  cause ;  while  in  others  there  were 
palpitation  of  the  heart,  sudden  inability  to  speak,  a 
sensation  of  suffocation,  or  a  feeling  of  drowsiness." 

Church  and  Peterson  t  quote  Lewis  as  having  noted 

*  "Familiar  Forms  of  Nervous  Diseases,"  p.  258. 
t  "Nervous  and  Mental  Diseases,"  p.  569. 


FORMS    OF    EPILEPTIC    AURA.  245 

an  elevation  of  body- temperature  during  the  aura, 
while  Voisin  has  observed  increased  temperature  in 
the  limbs  in  which  the  aura  originated.  Church* 
obtained  a  sphygmographic  tracing  showing  an  increase 
in  arterial  tension  before  the  fit,  a  fact  also  observed 
by  others. 

In  a  study  of  the  temperature  laws  in  epilepsy, 
made  by  the  writer, t  based  on  one  thousand  obser- 
vations, to  determine  the  degree  of  heat  preceding  or 
following  convulsions  of  various  kinds,  it  was  possible 
to  make  but  one  satisfactory  observation  on  the  tem- 
perature any  length  of  time  before  the  fit,  the  aura  in 
this  case  being  epigastric  and  appearing  two  hours  in 
advance.  The  temperature  was  normal  when  the 
aura  first  appeared,  but  immediately  began  to  rise,  and 
when  the  convulsion  occurred  two  hours  later,  had 
reached  1020  F. 

Clark  and  Sharp  J  refer  to  the  aura  in  forty  cases  of 
infantile  cerebral  palsy  associated  with  epilepsy,  as 
follows:  "Fourteen  patients  had  no  aura,  leaving 
twenty-six  who  had.  In  twenty  of  these  it  was 
sensory,  in  one  psychic,  one  olfactory,  one  auditory, 
and  in  three  visual. 

"  In  eight  of  the  sensory  type,  it  is  stated,  the  aura 
was  confined  to  the  paralyzed  side,  and  was  char- 
acterized as  painful,  the  other  sensory  aura  being 
distributed  between  epigastric,  cephalic,  and  feelings 
of  uneasiness. 

"  In  one  case,  in  which  the  epilepsy  followed  a 
paroxysm  of  whooping-cough,  the  aura  appeared  first 
in  the  nature  of  a  typical  Globus  hystericus,  and  was 
followed  by  evidences  of  pharyngeal  spasm  similar 
to  laryngismus  stridulus." 

It  is  now  generally  admitted  that  asthma  is  a  vaso- 

*  "Nervous  and  Mental  Diseases,"  p.  569. 

t  "The  Medical  News." 

%  "Pediatrics,"  Vol.  vn,  No.  7,  1899. 


246  FORMS    OF    EPILEPTIC    AURA. 

motor  neurosis  dependent  upon  irritation  of  the  sym- 
pathetic nerve,  the  seat  of  the  irritation,  according  to 
Glascow,*  lying  in  the  upper  portion  of  the  respiratory 
passages,  including  the  posterior  surfaces  of  the  tur- 
binates, the  inter-arytenoidal  commissure,  the  pos- 
terior surface  of  the  trachea,  and  the  membrane  at 
the  bifurcation  of  the  trachea. 

Bosworthf  quotes  Henry  Hyde  Salter  as  stating 
that  "  asthma  is  essentially,  perhaps  with  the  exception 
of  a  single  class  of  cases,  a  nervous  disease,  the  nerve 
centers  being  the  seat  of  the  essential  pathologic 
condition,"  a  proposition  which,  Bosworth  adds, 
"is  the  one  adopted  at  the  present  day." 

Elsewhere  we  refer  to  certain  asthmatic  affections 
as  constituting  forms  of  "epileptic  equivalents." 

As  a  rule,  the  more  sudden,  complete,  and  severe 
the  epileptic  attack,  the  less  likely  it  is  to  be  preceded 
by  an  aura ;  while  the  further  the  attack  departs  from 
the  classical  type,  the  more  frequent,  persistent,  and 
distinct  the  aura.  At  the  present  time  we  make  but 
little  use  of  these  important  initial  manifestations. 
They  justify  close  study  as  possible  guides  to  the  seat 
of  the  disease. 

*  "New  York  Medical  Journal,"  Aug.  25,  1900. 
t  "Diseases  of  the  Nose  and  Throat,"  p.  233. 


CHAPTER  IX. 
SEQUELS  OF  EPILEPTIC  CONVULSIONS. 

The  Effects  and  Results  of  Epileptic  Convulsions.  Proportion  of  Epileptics 
who  Sustain  Injuries.  Tongue  Scars.  Scars  of  Scalp  and  Face.  Burns. 
Hemorrhagic  Extravasations.  Fractures.  Dislocations.  Exhaustion  Paral- 
ysis      Body-temperature      Other  Effects,  General  and  Specific. 

Before  taking  up  the  study  of  diagnosis  proper,  it 
will  be  well  to  briefly  review  the  more  common, 
marked  phenomena  that  follow  epileptic  convulsions. 
Some  of  them  are  valuable  from  a  diagnostic  point 
of  view. 

The  effects  of  the  disease  on  the  mind — its  morbid 
psychology — will  be  studied  separately. 

In  825  cases  (500  men  and  325  women)  609  of  them, 
equal  to  74  per  cent.,  had  scars  on  some  part  of  the 
body  sustained  as  the  direct  results  of  epileptic  con- 
vulsions. More  men  than  women,  by  10  per  cent., 
presented  these  characteristics,  a  fact  explained  by 
the  wider  range  of  more  hazardous  vocations  indulged 
in  by  men  than  by  women. 

TONGUE    SCARS. 

We  customarily  look  for  a  scar  on  the  tongue  in  every 
case,  associating  injuries  of  that  organ  with  convul- 
sions, while,  as  a  matter  of  fact,  they  are  more  often 
absent  than  present. 

Injuries  of  the  tongue,  particularly  those  of  a  minor 
nature  received  during  an  epileptic  seizure,  heal 
readily  because  of  the  tongue's  vascularity  and  free- 
dom from  the  ordinary  sources  of  infection,  and 
when  not  very  severe,  generally  disappear  in  a  few 
weeks,  or  a  few  months'  time  at  the  most. 

It  occasionally  happens  that  the  tongue  is  bitten 

247 


248  SEQUELS    OF    EPILEPTIC    CONVULSIONS. 

through  its  thickest  portion,  or  a  piece  is  bitten  from 
the  side  or  tip.  When  this  happens,  the  scar  that 
follows  may  be  permanent. 

In  125  out  of  500  men,  and  in  60  out  of  325  women, 
there  were  one  or  more  tongue  scars  at  the  time  of 
examination,  being  about  22^  per  cent,  of  the  total 
number.  It  should  be  stated  in  this  connection  that 
when  the  search  for  scars  was  made,  these  825  patients 
were  having  about  200  seizures  a  day,  a  fact  which 
shows  how  recent  most  of  the  scars  may  have  been. 

I  recall  the  case  of  a  young  man  in  which  a  severe 
glossitis  followed  an  injury  to  the  tongue  during  an 
attack,  the  tongue  becoming  so  enormously  swollen, 
firm,  glistening,  and  white,  as  to  greatly  embarrass 
respiration,  causing  the  patient  great  discomfort. 
This  unique  result  of  a  fit  may,  in  rare  instances, 
justify   the   performance   of  tracheotomy. 

Fischer*  states  that  when  this  swollen  condition 
of  the  tongue  is  aggravated  by  paralysis  due  to  coma, 
death  may  be  the  result. 

SCARS  OF  THE  SCALP  AND  FACE. 

Among  the  825  patients  238  had  scars  about  the 
scalp  and  face,  the  favorite  localities  for  them  being 
the  forehead,  nose,  eyebrow,  chin,  cheek,  and  occiput, 
the  ears  occasionally  suffering  injury.  Most  of  these 
were  due  to  simple  incised  wounds  that  readily  healed 
under  proper  care.  The  greatest  danger  to  be  feared 
from  injuries  to  the  scalp  is  erysipelas,  a  complication 
not  infrequently  met  with. 

FRACTURES  AND  DISLOCATIONS. 

Among  the  same  cases  there  were  evidences  of 
fractures  in  29,  most  frequently  the  nose  and  clavicle 
being  broken;  the  skull,  legs,  arms,  and  ribs  occasion- 
ally. 

*  Fischer,    'Archives  of  Psychiatry,"  Vol.  xxxvi,  No.  2. 


Plate  ii. 


A  case  of  "alopecia  epileptica,"   the   bald    spot   developing  coincident]}' 
with  convulsions  that  followed  a  blow  on  the  occiput. 


Plate  12. 


Illustrating  a  skeleton  canvas  jacket,  devised  by  McBurney  for  use  at 
the  Craig  Colony,  to  prevent  dislocations  of  the  shoulder  during  convul- 
sions. Repeated  dislocations  of  the  shoulder  occur  during  attacks  in 
some  patients.     This  device  prevents  them. 


FRACTURES    AND    DISLOCATIONS.  249 

In.  the  absence  of  any  specific  investigations,  it 
cannot  be  said  whether  the  bones  of  epileptics  possess 
undue  fragility  or  not.  It  is  the  writer's  opinion, 
however,  that  in  certain  classes,  notably  the  old,  the 
rachitic  young  (in  which  the  condition  is  to  be  ex- 
pected), and  in  some  cases  of  long  standing  in  which 
the  patient's  stamina  is  thoroughly  vitiated,  the  bones 
may  break  easily. 

Reference  is  made  in  Tilton's  "  Text -book  on  Sur- 
gery" (p.  590)  to  fractures  of  the  clavicle  following 
the  brandishing  of  a  whip,  or  of  the  ribs  in  very  old 
persons  from  coughing;  while  Scudder  and  Keen 
both  speak  of  fractures  of  the  patella  as  being  "  usually 
caused  by  muscular  action,"  the  result  of  powerful 
contraction  of  the  quadriceps. 

Fischer  claims  that  contusions  and  fractures  are 
found. in  7.3  per  cent,  of  all  epileptics,  which  seems 
to  me  much  too  high.  This  author  expresses  the  belief 
that  the  bones  are  unduly  brittle  in  this  disease,  this 
condition  resulting  from  "local  or  general  trophic 
disturbances  caused  by  the  epilepsy  or  an  antecedent 
nervous  disorder. ' ' 

Fractures  caused  by  the  force  of  muscular  contrac- 
tion alone  during  very  severe  attacks  are  possible. 
A  male  epileptic,  thirty-eight  years  of  age,  mentioned 
to  me  by  Dr.  Rose,  went  to  bed  at  night  perfectly 
well,  and  the  following  morning  had  a  fracture  of  the 
knee-cap  and  an  intracapsular  fracture  of  the  femur, 
all  evidences  pointing  to  its  having  been  received 
during  a  convulsion. 

Dislocations  during  epileptic  convulsions  as  the 
results  of  muscular  contractions  alone  are  not  rare, 
eight  such  cases  having  come  under  my  observation. 
In  three  of  them  the  dislocations  were  almost  habitual, 
occurring  with  each  severe  convulsion;  in  one  the 
jaw  was  the  seat  of  the  dislocation;  in  the  other  two, 
the  shoulder.     Displacement  of  the  latter  occurred  in 


250  SEQUELAE    OF    EPILEPTIC    CONVULSIONS. 

one  case  four  or  five  times  a  month,  until  an  apparatus, 
shown  in  the  accompanying  illustration,  was  devised 
at  my  request  by  Dr.  Charles  McBurney.  When  it 
was  kept  properly  adjusted,  no  dislocation  occurred. 

Dislocations  occurring  during  the  fit  can  be  best 
reduced,  without  an  anesthetic,  during  the  relaxed  or 
comatose  period  which  follows,  and  before  the  fit  is 
over.  If  reduced  later,  an  anesthetic  must  generally 
be  used. 

BURNS. 

Burns  are  common  in  epilepsy,  as  shown  by  the  fact 
that  104  out  of  825  cases  presented  scars  caused  by 
falls  into  an  open  fire,  on  a  stove,  or  against  steam  or 
hot -water  heating-pipes  or  radiators. 

Disfiguring  and  painful  contraction  of  all  the  fingers 
follow  burns  caused  by  the  patient  grasping  a  pipe 
carrying  steam  or  hot  water,  and  convulsively  holding 
to  it  until  a  burn  to  some  extent  of  the  third  degree 
is  received. 

Severe  burns  about  the  face  may  be  caused  by  the 
patient  falling  against  a  hot-water  heater  and  remain- 
ing in  contact  with  it  some  time,  although  the  degree 
of  heat  in  it  may  not  exceed  from  1400  to  1500  F. 

The  deformities  that  follow  burns  due  to  epilepsy  are 
sufficient  to  make  up  a  distinct  group  in  themselves, 
while  in  certain  instances  they  may  be  looked  upon  as 
undeniably  stamping  the  victim  as  an  epileptic.  The 
illustrations  presented  in  this  connection  show  this 
point  quite  clearly.  Such  burns  mostly  occur  on  the 
hands,  arms,  and  face,  the  parts  most  exposed,  though 
no  part  of  the  body  is  exempt  when  the  patient  falls 
on  a  stove  or  an  open  fire. 

HEMORRHAGIC  EXTRAVASATIONS. 

Extravasations  of  blood  in  the  conjunctivas  during 
the  severer  forms  of  convulsions  are  by  no  means  rare, 
seeming  to  occur  more  often  in  the  outer  portion  of 


Plate  13. 


Severe  burn  of  face  causing  loss  of  right  ear,  and  the  substitution  by  the 
patient  of  an  artificial  ear  made  by  tumseli. 


Plate  14. 


Illustrating  common  forms  of  disfigurement  in  epilepsy,  due  to  burns.     In 
this  case  the  beard  covers  the  most  unsightly  scars  about  the  mouth. 


Plate  15. 


Showing  loss  of  fingers  on  one  hand  due  to  a  burn  received  while  in  an 
epileptic  attack. 


Plate  16. 


Extensive  burn  of  the  face  that  threatened  destruction  of  the  eyesight, 
caused  by  falling  in  the  fire  during  an  epileptic  attack. 


HEMORRHAGIC    EXTRAVASATIONS.  25 1 

the  conjunctivae  and  having  a  tendency  to  spread,  so 
that  an  injected  spot  half  the  size  of  a  grain  of  corn 
in  the  beginning  may  extend  in  two  or  three  days 
until  it  almost  covers  the  whole  eye. 

I  do  not  recall  having  seen  a  case  in  which  the  hemor- 
rhage occurred  in  the  vessels  within  the  eye.  Gowers 
states  that  he  has  often  searched  for  retinal  hemorrhage 
in  such  cases,  but  always  without  result. 

Hughlings-Jackson  has  described  what  he  terms 
"retinal  epilepsy,"  a  condition  of  spasm  in  the  retinal 
vessels  during  epileptic  attacks  which  causes  moment- 
ary blindness. 

Punctiform  hemorrhages  covering  one  side  of  the 
face  and  neck  are  likewise  not  infrequent  after  grand 
mat  attacks  in  certain  individuals.  This  condition 
is  noticed  as  soon  as  the  fit  is  over,  the  face  having 
a  dark,  diffusely  mottled  appearance,  without  eleva- 
tion, the  discoloration  partly  disappearing  under 
pressure,  to  quickly  return  when  it  is  removed. 

As  a  rule,  such  extravasations  are  visible  for  some 
days  afterward,  first  fading  in  changing  colors  like 
a  bruise. 

The  fact  that  the  face  suffers  most  is  probably  due 
to  the  constricting  band  of  clothing  about  the  turgid 
neck,  which  increases  the  effects  of  the  mechanical 
congestion. 

When  death  follows  a  very  severe  convulsion,  or  a 
series  of  them,  like  status,  similar  punctiform  hemor- 
rhages are  seen  in  the  brain,  more  particularly  in  the 
white  matter,  in  the  pericardium,  and  in  the  mem- 
branes of  the  spinal  cord. 

Hare  quotes  Sandras*  as  recording  a  "disposition 
singidaire  et  inexplicable"  in  the  skin  of  epileptics, 
who,  when  exposed  to  the  sun  become  covered  on  the 
face  and  generally  elsewhere  on  the  body,  with  numer- 
ous "  taches  rosees"  without  any  elevation,  and  which 
disappear  when  the  person  goes  into  the  shade. 

*  "Epilepsy:  Its  Etiology  and  Pathology,"  p.  35. 


252  SEQUELS    OF    EPILEPTIC    CONVULSIONS. 

I  have  never  witnessed  any  such  phenomena.  The 
changing  color,  as  described  by  Sandras,  may  have 
been  due  to  rapidly  occurring  psychic  attacks,  the 
effects  produced  being  due  to  changes  in  vascularity. 
It  is  not  uncommon  for  epileptics  of  this  type  to  have 
a  seizure  and  "change  color"  from  seventy-five  to 
one  hundred  times  or  more  in  a  single  day. 

Echeverria  reports  the  case*  of  a  woman  of  thirty 
years,  who  had  a  general  petechial  eruption  on  the  face, 
neck,  and  limbs  as  the  result  of  "petit  mat  attacks 
occurring  in  the  daytime  and  spasms  in  the  night," 
the  former  being  ' '  constantly  succeeded  by  fits  of 
laughter  and  mania."  The  eruption  that  came  on 
after  the  nocturnal  attacks  was  minute  and  confluent 
in  character,  and  generally  passed  off  within  two  or 
three  days.  The  same  writer  mentions  a  similar  case 
reported  by  Chatelet. 

L.  Pierce  Clark  f  reports  the  case  of  a  young  woman, 
seventeen  years  of  age,  of  a  neurotic  family,  whose 
epilepsy  followed  scarlatinal  nephritis  at  the  seventh 
year,  the  attacks  being  largely  motorial  in  character. 
She  was  accustomed  to  exhibit  a  profuse  subcutaneous 
hemorrhage  on  the  right  side  of  the  face  and  neck 
after  each  attack. 

The  discoloration  remained  very  pronounced  for 
two  days,  when  it  began  to  gradually  fade  out.  This 
occurrence  was  apparently  prevented  from  recurring 
by  small  doses  of  the  fluid  extract  of  ergot. 

EXHAUSTION-PARALYSIS. 

Exhaustion-paralysis,  or  a  more  or  less  complete 
but  temporary  loss  of  function  of  some  part  of  the  body 
may  follow  certain  types  of  epileptic  seizures.  This 
condition  of  transient  paralysis  in  epilepsy  was  first 
carefully  observed  by  Bravais  in  1824,  as  mentioned 

*  "Epilepsy,"  p.  284. 

t"The  Medical  Record,"  March  26,   1898. 


EXHAUSTION-PARALYSIS.  253 

in  his  work  on  hemiplegic  epilepsy.  The  condition 
was,  however,  known  many  years  before  to  French 
investigators.  Among  those  who  have  chiefly  in- 
vestigated the  nature  and  cause  of  the  state  may  be 
mentioned  Todd,  Robertson,  Jackson,  Gowers,  and 
Fere.  No  new  contribution  to  our  knowledge  of  the 
phenomenon  has  appeared  since  the  eighties,  save 
the  elaborate  work  of  L.  Pierce  Clark.* 

Some  degree  of  paralysis,  exhaustive  in  nature,  is 
not  rare  after  Jacksonian  or  partial  epilepsy,  and  may 
be  easily  demonstrated  in  cases  in  which  consciousness 
is  retained  during  the  fit;  it  probably  occurs  in  some 
degree  after  every  attack  in  this  form  of  epilepsy. 
The  fewer  the  muscles  affected  by  the  fit,  the  greater 
will  be  the  subsequent  weakness,  inasmuch  as  it  is  a 
result  of  a  local  and  complete  discharge  of  one  par- 
ticular motor  area.  The  phenomenon  may  occasion- 
ally follow  Jacksonian  attacks  in  idiopathic  epilepsy 
in  which  the  convulsion  is  confined  to  one  side  or 
extremity.  The  motor  weakness  more  or  less  rapidly 
disappears  after  single  fits,  but  when  it  results  after 
serial  or  status  periods  in  which  the  fits  are  partial 
in  type  and  range,  the  paralysis  may  be  fully  as  com- 
plete as  that  seen  after  an  apoplectic  stroke,  and  it 
may  remain  more  or  less  marked  for  days  or  weeks. 

In  rare  cases  of  idiopathic  epilepsy  the  paralysis  has 
been  known  to  persist  as  an  anomalous  type  of  hemi- 
plegia. The  true  nature  of  such  permanent  palsies  is 
still  a  matter  of  doubt,  although  one  of  L.  Pierce 
Clark's  cases  showed  no  evidence  of  a  destructive 
lesion  at  the  autopsy.  Cases  of  permanent  exhaustion- 
palsy  must  not  be  confused  with  old  unrecognized 
palsies  of  infantile  type,  in  which  the  lesion  is  made 
prominent  once  more  as  a  result  of  epileptiform  seiz- 
ures,   and    upon    which    the    seizures    depend.     The 

*  "Clinical  Studies  in  Epilepsy,"  "Archives  of  Neurology  and  Psycho- 
pathology  "  Vol.  11,  1899. 


254  SEQUELiE    OF    EPILEPTIC    CONVULSIONS. 

paralysis  is  always  most  marked  in  those  parts  which 
are  engaged  most  in  the  convulsion.  It  is,  therefore, 
an  exhaustion  of  cortical  elements;  in  other  words, 
it  is  a  problem  in  fatigue  of  cortical  elements  and  not 
of  muscles  alone. 

It  is  quite  probable  that  the  general  exhaustion 
which  follows  general  fits  and  which  is  covered  by 
coma  may  be  analogous  to  the  local  weakness  here 
described.  In  rare  instances  a  loss  of  function  (sensory 
in  type  instead  of  motor)  of  some  one  of  the  special 
senses  may  occur;  such  as,  for  example,  the  sudden 
unilateral  deafness  or  blindness  on  that  side  engaged 
most  in  the  convulsion.  The  occurrence  of  a  special 
sense  loss  without  some  evidence  of  convulsion  or 
other  symptoms  of  a  seizure,  should  be  counted  of 
hysterical  origin.  Good  observers,  however,  claim  to 
have  noted  bodily  paralysis  without  convulsion  (Low- 
enfeld,  Heidenhain,  and  Gowers).  They  believe  the 
paralysis  is  the  result  of  sudden  inhibition  of  cortical 
motor  elements.  However  true  these  observations 
may  be,  Clark  has  never  observed  it,  nor  have  I 
been  able  to  satisfy  myself  that  some  convulsion 
had  not  taken  place  in  such  cases.  Undisputed  evi- 
dence of  inhibition  paralysis  in  epilepsy  can  be  afforded 
only  when  the  hands  of  the  observer  are  placed  directly 
upon  the  muscles  themselves,  a  rule  for  the  study  of 
convulsions  of  first  importance  and  too  little  empha- 
sized by  many  observers.  It  is  extremely  doubtful 
that  any  fit  may  occur  without  some  motor  mani- 
festation. 

We  can  generally  diagnosticate  the  exhaustive 
nature  of  the  palsy  in  epilepsy  without  a  previous 
history  by  noting  the  absence  of  spasticity,  atrophy, 
and  vasomotor  changes,  all  of  which  are  common  in 
old  organic  hemiplegics.  If  the  patient  has  had  a 
series  of  seizures  and  an  old  organic  lesion  also  exists, 
we  may  assure  the  friends  of  the  patient  that  the 


EXHAUSTION-PARALYSIS.  255 

increased  paralysis  will  disappear  in  greater  part  in  a 
few  days  after  the  cessation  of  the  seizures. 

The  illustrations  presented  in  conjunction  with  two 
cases  show  the  commoner  forms  of  exhaustion  paral- 
ysis: 

Case  I. — F.  R.,  a  man  aged  fifty-three  years;  iron- 
worker by  occupation;  age  at  onset  of  epilepsy,  fifty 
years.  The  cause  was  ascribed  to  grippe,  but  the 
patient  has  undoubtedly  used  alcohol  to  great  excess. 
No  neurotic  history  was  obtainable.  His  seizures 
were  not  preceded  by  any  aura.  The  reflexes,  both 
superficial  and  deep,  were  normal  on  admission, 
March  25,  1896.  There  was  a  slight  muscular  tremor 
in  the  hands  and  lips. 

On  April  6th  he  began  to  have  an  average  of  twelve 
seizures  in  twenty-four  hours.  After  the  first  two 
days  these  attacks  were  followed  by  a  partial  hemi- 
plegia of  the  right  side ;  after  the  first  six  days  he  was 
able  to  move  his  fingers  only.  The  epileptic  seizures 
were  always  of  a  general  convulsive  character.  For  the 
first  few  days,  and  whenever  these  seizures  would 
cease  for  two  or  three  hours,  he  could  perform  some 
of  the  very  simple  movements  of  the  arm  and  leg  of  the 
affected  side.  Fig.  11,*  pose  of  F.  R. ,  shows  the  patient 
with  the  seizure  involving  the  left  side  first  and  begin- 
ning to  involve  the  right  side  of  head.  Fig.  1 2  of  the 
same  convulsion  shows  the  seizure  finally  ending  on 
the  right  side  in  the  extreme  tonic  convulsion,  proving 
the  right  side  to  be  the  one  most  involved  in  point  of 
intensity.  Fig.  13  shows  the  same  patient  some  days 
later  in  convulsion  with  the  right  side  put  entirely 
out  of  action,  as  it  were,  because  of  the  apparently 
complete  exhaustion  of  that  side  remaining  from  pre- 
vious attacks  like  those  shown  in  Figs.  11  and  12.  The 
left  side  alone  remained  capable  of  carrying  on  the 
convulsion  phenomenon  in  subsequent  seizures.  The 
deep  reflexes  of  the  right  side  were  very  much  exag- 
gerated; all  through  his  series  of  attacks  ankle-clonus 
was  a  prominent  symptom.     Plantar  reflex  was  always 

*  The  negatives  taken  from  the  actual  convulsion  were  too  faint  to  allow 
of  reproduction,  but  were  used  as  guides  in  these  poses  (of  Figs,  n,  12,  and 
13)  which  are  particularly  accurate. 


256  SEQUELAE    OF    EPILEPTIC    CONVULSIONS. 

obtainable  and  was  markedly  exaggerated  toward  the 
end  of  the  series. 

During  the  nineteen  days  following  the  first  attack 
he  had  249  distinct  and  separate  convulsive  seizures. 

On  April  21st  he  began  to  have  fewer  attacks  daily, 
and  on  the  25th  he  had  only  one;  for  the  next  eight 


Fig.   11. 


Fig.   12. 


days  he  had  but  one  attack  a  day.  At  the  time  he 
began  to  have  but  three  attacks  a  day  he  slowly 
picked  up  some  of  the  less  complex  and  comparatively 
simple  muscular  movements.  Throughout  the  entire 
period  the  superficial  and  deep  reflexes  remained  ex- 
aggerated  and   were   much   more   noticeable   on   the 


EXHAUSTION-PARALYSIS.  257 

affected  side.  A  small  corneal  ulcer  made  its  appear- 
ance on  the  24th,  and  a  bedsore  began  on  the  right 
buttock  the  next  day.  Both  were  healed  very  quickly 
by  local  application.  During  this  time  the  patient 
lost  twenty  pounds  in  weight.  From  April  24th  to 
May  15  th  he  made  uninterrupted  progress  toward  re- 
covery of  almost  all  of  the  muscular  movements,  but 
there  still  remained  some  slight  paralysis  of  the  more 
complex  muscular  movements.  The  deep  reflexes  of 
the  left  side  at  first  were  less  than  the  right,  and  below 
a  normal  reflex.  This  condition  persisted  until  the 
stated  improvement  began;  then  they  became  exag- 
gerated equally  with  the  right  side. 

The  patient's  condition  six  months  after  his  paralysis 
was  as  follows:  The  knee-jerks  of  both  sides  were 
exaggerated,  the  right  more  than  the  left;  ankle- 
clonus  was  still  obtainable  in  both  sides,  although 
more  marked  on  the  right;  both  wrist- jerks  were 
markedly  exaggerated,  the  right  greater  than  the  left. 
The  right  pupil  was  incoordinate  in  its  adaptation  to 
light,  and  the  patient  was  incoordinate  in  his  attempts 
to  perform  many  of  the  more  complex  muscular  acts 
involving  muscles  of  the  affected  side.  He  stated  that 
he  was  "very  awkward  and  clumsy." 

An  examination  made  in  April,  1898  (two  years 
after  his  attack),  showed  complete  recovery  of  all  the 
paralyses.  Several  attacks  occurring  in  series  since, 
attended  by  temporary  paralysis,  prove  the  ex- 
haustive nature  of  the  resulting  paralyses.  The 
patient  is  at  present  (October  1,  1899)  doing  a  full 
day's  work  at  his  trade  (that  of  a  blacksmith),  having 
occasional  isolated  epileptic  fits.* 

Case  II. — M.  E.  H.,  a  girl  aged  twelve  years.  Epi- 
lepsy began  at  four  years  and  a  half.  Neurotic  family 
history.  Seizures  dated  from  infantile  cerebral  palsy 
with  left  hemiplegia.  During  the  first  two  years  of 
epilepsy  the  convulsions  were  confined  to  the  left 
side,  but  later  became  general.     There  were  occasional 

*  Note  by  the  author:  June,  1903.  The  patient's  condition  is  more 
satisfactory  now  than  when  the  last  note  was  made  in  1899.  He  is  robust 
and  hearty  in  every  respect,  showing  no  sign  of  exhaustion-paralysis  in  any 
degree.  During  1900  he  had  145  seizures,  during  1901,  59,  and  during 
1902,  66;  none  of  them  being  followed  by  the  condition  described  above. 
17 


258 


SEQUELAE    OF    EPILEPTIC    CONVULSIONS. 


petit  mal  attacks.  There  was  a  loss  of  speech  with  left 
side  palsy.  The  patient  recovered  sufficient  power  in 
the  hemiplegic  side  to  walk  to  some  extent  after  five 
months  from  the  onset  of  the  palsy.  At  various  periods 
during  the  past  two  years  the  patient  had  a  series  of 
eight  or  ten  convulsions  in  forty-eight  hours,  the  left 
side  being  chiefly  involved.  An  after-palsy  nearly 
complete  lasted  from  one  to  two  days.  Atrophy  was 
most  marked  distally ;  there  was  but  little  contracture. 
Extremities  of  both  sides  were  equal  in  length.  All 
reflexes  of  the  left  side  were  exaggerated. 

In  July,  1 898,  typi- 


cal exhaustion  par- 
alysis supervened 
upon  the  left  (pal- 
sied) side,  leaving 
that  side  completely 
hemiplegic  for 
weeks.  The  right 
side  remained  un- 
affected. Seizures 
convulsed  the  left 
side  most,  beginning 
and  ending  on  the 
left  side.     (See  Fig. 

14.) 

The  exhaustive 
phenomenon  of  the 
right  side  and  arm 
was  first  manifest  in 
the  series  of  attacks 
from  September 
28th  to  October  8, 
1898.  The  tempera- 
ture on  September 
30th  reached  1060 
F.,  pulse  168,  respi- 
ration 60;  two  hundred  and  sixty-three  seizures  oc- 
curred that  day,  mainly  localized  in  the  right  side 
and  predominating  in  the  right  arm.  This  is  admir- 
ably shown  in  Text-figure  1 5  drawn  from  the  photo- 
graph. The  left  arm  remained  free  from  convulsion. 
On  October  8,  1898,  the  fingers  of  the  right  hand 
assumed  a  state  of  athetoid  spasm   (Strumpell) ;  the 


Fig.  14.  Fig.  15. 

j?  indicates  slight  convulsion. 
: :  indicates  slight  paralysis. 
£    indicates  severe  convulsion. 
X  indicates  severe  paralysis. 


EXHAUSTION-PARALYSIS.  259 

index  finger  was  extended;  the  thumb  was  flexed  to 
the  side  of  the  metacarpal  phalangeal  joint,  and  over 
the  third  and  little  fingers  in  semi-flexion  at  the  second 
joint.  The  third  and  little  fingers  were  flexed  only  at 
the  knuckle ;  other  joints  of  the  fingers  were  nearly- 
straight.  Continuous  slight  fibrillary  tremor  was 
found  in  all  fingers,  especially  the  third  and  little 
fingers.  Earnest  voluntary  effort  enabled  the  fingers 
to  be  partially  extended  at  the  knuckles,  but  such 
effort  was  attended  by  some  pain  and  performed  very 
slowly.  Painful  contracture  which  complicates  palsy 
is  called  by  some  the  post-epileptic  paralytic  equiva- 
lent. 

On  December  14th  paralysis  continued  most  marked 
in  the  right  upper  extremity.  The  right  hand  at  rest 
frequently  assumed  Strumpell's  typical  athetoid  posi- 
tion. The  movements  of  the  fingers  were  mostly  those 
of  mobile  spasm;  no  tremor  was  noticed;  there  was 
much  less  contracture  than  formerly.  Upon  strong 
volitional  effort,  considerable  power  was  manifest  in 
the  hand.  The  right  shoulder  and  arm  muscles  still 
appeared  weak.  The  extremity,  as  a  whole,  was  lifted 
very  slowly  and  with  great  effort.  The  right  hand  was 
cold  and  the  circulation  was  very  poor. 

On  January  8th  severe  convulsions  occurred  at 
8.45  a.  m.  and  3.25  p.  m.,  both  similar  in  character, 
and  affecting  the  left  side  most,  although  apparently 
general.  This  was  followed  by  carpopedal  contrac- 
tures, beginning  immediately  after  convulsion  and 
continuing  for  thirteen  minutes,  gradually  diminishing 
in  severity  toward  the  last.  During  the  first  six 
minutes  the  left  arm  and  right  leg  were  most  affected ; 
afterward  the  right  side  alone  was  involved.  The  toes 
of  the  right  foot  were  in  hyperextension,  the  foot  in- 
clined inward  from  the  ankle;  the  leg  was  flexed  at 
the  knee  (this  position  was  taken  suddenly,  the  leg 
being  immediately  straightened  when  contracture 
subsided).  The  right  hand  was  semiflexed  and  the 
wrist  completely  flexed,  the  arm  remaining  straight. 

A  slight  convulsion  occurred  at  3.00  p.  m.,  followed 
by  carpopedal  contractures  affecting  the  left  side 
most;  it  continued  for  ten  minutes.  There  was  slight 
weakening  of  the  left  side:  the  right  side  remained 
unchanged. 


260  SEQUELAE    OF    EPILEPTIC    CONVULSIONS. 

On  February  10,   1899,  the  patient  had  two  kinds 
,  of  paralysis.     The  left  side  had  flaccid,  soft,  and  atro- 
phied muscles,  giving  a  spastic  gait ;  the  right  side  was 
in  slight  rigidity  and  contracture,  giving  ataxic  gait. 
This  condition  showed  constant  improvement. 

The  degree  of  the  paralysis  of  the  left  side  is  de- 
pendent on  the  severity  and  frequency  of  the  attacks. 
Cessation  of  attacks  for  a  few  days  allows  the  side  to 
return  to  the  normal  inter-paroxysmal  paretic  state. 
Although  in  severe  series  the  convulsions  are  confined 
mostly  to  the  left  side  at  first,  they  change  to  the 
right  side  almost  entirely.  They  apparently  do  not 
do  this  until  there  is  complete  paralysis  of  the  left 
side.  Exhaustion-paralysis  then  rests  upon  an  organic 
paralysis,  producing  complete  paralysis. 

The  cerebral  center  of  the  right  side,  being  left 
alone  to  carry  on  the  convulsive  state,  is  soon  ex- 
hausted and  becomes  more  or  less  paralytic,  but  will 
recover  again  more  or  less  completely  if  allowed  to 
rest  for  any  marked  period. 

BODY-TEMPERATURE. 

Bourne ville,  assisted  by  Lemoine,  was  the  first  to 
study  the  question  of  increased  temperature  following 
an  epileptic  convulsion.  His  earlier  studies  dated 
from  1869  to  1886,  while  he  made  a  second  series  of 
observations  extending  from  the  latter  year  to  1900. 
After  his  first  work,  the  results  given  by  him  were 
repudiated  by  Witkowski,  which  led  Bourne  ville  to 
repeat  all  he  had  done  in  a  most  careful  manner,  pre- 
senting conclusive  evidence  on  every  point. 

So  satisfactorily  did  Bourneville  do  his  work  in  the 
first  instance  that  Charcot  and  other  eminent  teachers 
of  the  day  dogmatically  taught  that  there  was  a  rise 
of  temperature  after  epileptic  convulsions. 

Bourneville's  and  Lemoine's  work  was  based  upon 
over  500  examinations.     Of  these  Bourneville  reported 


BODY-TEMPERATURE.  261 

64  cases  in  1886,  but  it  is  not  yet  apparent  when  these 
investigations  were  made.  In  his  "  Recherches  sur 
l'epilepsie,"  etc.,  for  1886-1887,  he  reports  109  cases. 
In  the  same  "Recherches  for  1891"  he  reports  66  ob- 
servations, none  of  which  were  made  prior  to  1888. 
Lemoine  in  1888  reports  182  cases.  The  grand  total 
is  520  cases. 

As  a  general  rule,  the  majority  of  these  observations 
follow  a  law  and  may  be  described  as  typical,  while  a 
small  minority  are  atypical.  Of  the  first  series  of  64, 
60  were  typical;  of  the  second  series  of  109,  82  were 
typical;  of  the  66  cases,  58  were  typical.  Lemoine, 
who  considered  the  subject  from  a  broader  standpoint, 
found  in  his  182  cases  only  a  solitary  exception  to  his 
normal,  or  type.  Lemoine  assumed  that  certain  cases 
were  naturally  anomalous  in  the  matter  of  temperature, 
having  abnormally  low  temperature  in  health;  hence 
the  anomaly  in  these  cases  is  not  referable  to  the 
epilepsy,  but  to  the  patient  himself.  From  Bourne- 
ville's  standpoint  there  would  be  about  92  per  cent, 
typical,  and  from  Lemoine' s  point  of  view  upward  of 
99  per  cent. 

Isolated  Attacks. — Bourneville's  conclusions  were  as 
follows:  (1)  Isolated  attacks  of  epilepsy  augment  the 
central  temperature;  (2)  this  augmentation  varies 
from  .i°  up  to  1. 50  and  even  higher  at  times.  The 
average  rise  is  about  .5°  or  .6°. 

Serial  Attacks. — In  Bourneville's  article,  published  in 
1 89 1,  he  gives  his  observations  on  four  cases  of  serial 
attacks  in  which  he  took  three  temperatures  as  follows : 
The  first  at  a  given  time,  the  second  twelve  hours 
later,  and  the  third  eighteen  hours  later.  Of  these 
four  cases  there  were  respectively  five,  fifteen,  twenty, 
and  nine  attacks  in  one  day.  The  first  temperature 
was  taken  at  the  moment  of  stertor  after  an  access. 
In  all  the  cases  the  initial  temperature  was  the  highest, 
and  the  readings  at  twelve  and  eighteen  hours  were 


262  SEQUELS    OF    EPILEPTIC    CONVULSIONS. 

progressively  lower.  The  initial  temperature  varied 
from  380  to  38. 6°  C. ;  the  twelve-hour  temperature  from 
3 7. 8°  to  3 8°  C,  and  the  eight een-hour  temperature 
from  3 7. 30  to  37. 8°  C.  It  would  appear,  therefore, 
that  these  cases  do  not  differ  materially  from  ordinary 
isolated  cases. 

Status  Epilepticus. — This  clinical  phenomenon  was 
first  clearly  described  by  Bourneville.  He  character- 
ized it  as  follows:  (1)  Attacks  incessantly  repeated  so 
that  they  overlap  one  another  (subintrant  attacks); 
(2)  terminate  in  collapse  variable  in  degrees  up  to  the 
most  absolute  and  fatal  coma;  (3)  may  end  in  hemi- 
plegia; (4)  pulse  and  respiration  always  increased ;  (5) 
considerable  elevation  of  temperature,  which  persists 
during  the  (brief)  intervals  between  convulsions  and 
increases  even  when  the  convulsions  have  ceased. 

Bourneville  gives  several  fatal  cases  in  which  the 
temperature  ran  up  respectively  to  40. 8°,  42 °,  42.40, 
and  40. 90  C.  In  1892  Bourneville  reported  a  similar 
case  in  which  the  temperature  was  taken  up  at  death. 
The  record  shows  that  the  temperature  increased 
slightly  each  day  until  at  death  it  was  40. 20  C. 

Intermediate  Cases. — Bourneville  reports  two  cases 
which  he  considers  stand  midway  between  ordinary 
serial  attacks  and  the  status  epilepticus.  These  are 
given  in  his  "  Recherches  sur  l'epilepsie,"  etc.,  1891, 
but  are  not  especially  significant,  being  thoroughly 
unique  and  atypical. 

Personal  Observations. — My  own  studies  of  the  tem- 
perature laws  in  epilepsy,  made  in  1901,*  extended 
over  fifteen  months  and  covered  1000  records  made 
in  250  cases.  These  included  all  types  of  the  disease, 
though  in  some  of  them,  such  as  the  so-called  hystero- 
epilepsy,  a  sufficient  number  of  observations  could  not 
be  made  to  warrant  any  general  deductions  being  drawn. 

*  "  A  Study  of  the  Temperature  Laws  in  Epilepsy  based  on  One  Thousand 
Observations,"  "Medical  News,"  September  7,  1901. 


BODY-TEMPERATURE.  263 

The  1000  observations  were  divided  into  seven 
groups,  as  follows: 

Group        I.   516  grand  mal  seizures. 

Group      II.    133  petit  mal  seizures. 

Group    III.   81  psychic  seizures. 

Group  IV.  50  grand  mal  seizures  with  extended 
observations. 

Group  V.  25  petit  mal  seizures  with  extended 
observations. 

Group     VI.   1 7  cases  of  status  epilepticus. 

Group  VII.   5  cases  of  serial  attacks. 

Group  I. — This  group  comprised  516  grand  mal 
seizures.  The  average  duration  of  all  the  seizures, 
including  the  stage  of  active  convulsions  only,  was  a 
fraction  over  one  minute  and  three  quarters,  the 
longest  being  five  minutes,  the  shortest  half  a  minute. 
A  single  fit  lasted  only  five  minutes  with  a  temperature 
of  99. 6°  F.  immediately  after,  dropping  to  normal 
thirty  minutes  later.  In  five  cases  the  fit  lasted  four 
minutes,  all  followed  immediately  after  by  increased 
temperatures,  ranging  from  99. 20  to  100. 6°  F.  In  ten 
others,  in  which  the  fit  lasted  half  a  minute  only,  the 
temperature  was  increased  in  all  from  .2°  to  3.5°. 
This  fact  is  mentioned  to  show  the  apparent  lack  of 
value  in  comparison  between  heat  elevation  following 
seizures  of  long  duration,  as  compared  with  those  of 
short  duration. 

Taking  the  516  grand  mal  seizures  collectively,  it 
will  be  seen  that  297  (57^  per  cent.)  showed  an  increase 
in  temperature  ranging  from  .2°  to  3.50  immediately 
after  the  fit.  Again,  taking  the  same  group  of  cases, 
it  is  seen  that  80  (15^  per  cent.)  showed  subnormal 
temperatures  immediately  after  the  fit,  ranging  from 
96. 40  F.  in  one  case  to  from  970  to  980  F.  in  thirty-one 
others.  As  this  subnormal  group  will  not  be  referred 
to  again,  it  may  be  well  to  state  here  that,  after 
careful  study,  I  have  been  unable  to  assign  any  cause 


264  SEQUELS    OF    EPILEPTIC    CONVULSIONS. 

for  the  low  temperature  in  these  cases,  other  than  the 
causes  that  operate  generally  to  produce  low  tempera- 
tures in  other  conditions,  such  as  chronic  asthenic 
diseases  of  long  standing,  defective  nutrition,  idiocy, 
imbecility,  and  epileptic  dementia  complicated  with  or 
without  paraplegic  or  hemiplegic  infirmities. 

Turning  again  to  the  516  grand  mal  seizures,  it  will 
be  noted  that  while  297  (57^  per  cent.)  showed  in- 
creased temperature  immediately  after  the  fit,  330 
(66  per  cent.)  showed  an  increase  half  an  hour  later, 
the  highest  temperature  being  102.20  F. ;  the  lowest, 
9 7. 4°  F.  At  the  third  observation,  an  hour  after  the 
fit,  327  (64  per  cent.)  gave  temperature  increases 
above  the  normal,  ranging  from  .2°  to  3.50. 

Group  II. — The  average  duration  of  the  fit  in  this 
group  was  one  and  two -tenths  of  a  minute,  the  longest 
being  four  minutes,  the  shortest  fifteen  seconds. 

Immediately  after  the  fit  80  (60  per  cent.)  showed 
increased  temperatures  ranging  from  .2°  to  2.50  above 
normal,  while  a  subnormal  record  was  made  in  14  (10 
per  cent,  of  the  entire  number),  the  proportion  of 
subnormals  being  less  in  this  group  by  33  per  cent, 
than  in  the  previous  grand  mal  group.  The  same  133 
cases  presented  at  the  end  of  half  an  hour  increased 
temperatures  in  94,  or  70  per  cent.,  ranging  from  .2° 
to  4. 50  above  normal,  while  at  the  end  of  an  hour 
after  the  fit  only  70  (52^  per  cent.)  still  showed  an 
increase. 

Group  III. — The  average  duration  of  the  fit  in  this 
group  was  about  one  minute.  Immediately  after  the 
fit  49  (60  per  cent.)  gave  increased  temperatures 
ranging  from  .2°  to  i.8°  above  normal.  After  half  an 
hour  56  (69  per  cent.)  still  showed  an  increase ;  while  at 
the  end  of  an  hour  54  (67^  per  cent.)  showed  relatively 
.the  same  heat  elevations. 

Group  IV. — In  this  group,  26  (52  per  cent.)  showed 
temperature    increases    that    ran    uniformly    through 


BODY-TEMPERATURE.  265 

all  the  record  hours ;  that  is,  those  showing  an  increase 
immediately  after  the  fit  showed  relatively  the  same 
increase  at  the  end  of  the  second  hour.  It  may  also 
be  noted  that  14  cases  of  this  group,  which  showed 
low  temperatures  immediately  after  the  fit,  showed  still 
lower  temperatures  two  hours  later,  many  of  them 
dropping  from  slight  increases  above  normal  to  sub- 
normal. 

Group  V. — In  this  group  13  (52  per  cent.)  showed 
increased  temperatures  immediately  after  the  fit. 
An  hour  after  16  (64  per  cent.)  showed  increase; 
while  at  the  end  of  the  second  hour  after  the  fit  17 
(68  per  cent.)  showed  relatively  greater  increases  than 
were  noted  immediately  after  the  fit. 

None  of  the  seizures  of  this  group  were  violent  or 
severe,  none  lasting  more  than  sixty  seconds,  so  that 
in  looking  for  the  cause  of  heat  elevation  in  them  we 
feel  justified  in  at  once  excluding  muscular  activity. 
In  many  of  them  the  muscles  did  not  play  any  more 
important  part  than  that  required  for  the  fibrillary 
contractions  of  some  of  the  muscles  of  expression, 
chiefly  those  about  the  mouth,  which  are  so  frequently 
seen  in  petit  mat  and  psychic  seizures. 

It  is  not  possible  for  such  muscular  activity  to  in- 
crease the  temperature  of  the  body  to  ioo°  F. ;  and 
in  such  cases  it  is  entirely  within  reason  to  assume 
that  there  has  been  a  disturbance  in  the  central  nervous 
system,  either  in  the  thermal  cortical  centers  described 
by  Landois  and  Stirling,  or,  since  motion  in  such  cases 
is  so  significant,  in  the  lower  heat  centers  in  the  corpus 
striatum  and  optic  thalamus. 

It  is  a  well-established  fact  in  pathology  that  in 
disease  involving  the  highest  specialized  tissues  of  the 
body,  recovery  takes  place  at  a  much  slower  rate 'than 
when  grosser  tissue  is  involved.  By  analogy,  the  same 
thing  is  true  here.  Increased  heat  of  the  body,  due 
to    simple    increase    in    muscular    action,    will    more 


266  SEQUELS    OF    EPILEPTIC    CONVULSIONS. 

quickly  pass  away  than  when  such  increase  is  due  to  a 
deep-seated  disturbance  of  the  heat  centers  of  the  brain. 

Group  VI.— The  fact  that  status  epilepticus  is  so 
often  accompanied  by  high  temperature  is  so  well 
known  that  further  arguments  on  this  line  would 
be  superfluous.  This  group  is  presented  more  to 
make  the  study  of  the  temperature  laws  in  epilepsy 
as  complete  as  possible  than  for  any  other  purpose. 
The  lowest  status  temperature  was  102.40  F. ;  the 
highest,  1 07. 50'.  In  all  the  temperature  ran  up  to 
1 04°  F.  and  over,  and  in  nine  cases  to  1050  F.  and 
over;  while  1070  F.  and  over  was  reached  in  two  cases. 

Group  VII. — -The  difference  between  the  duration 
of  the  attacks  in  this  group,  as  compared  with  the 
duration  in  the  status  group,  and  further  compared 
as  to  the  temperatures  that  followed  in  each,  is  ap- 
parent at  a  glance.  The  highest  temperature  follow- 
ing serial  attacks  was  105. 8°  F.,  the  seizures  that  caused 
it  numbering  140,  covering  a  period  of  ninety-six  hours. 
In  none  of  the  remaining  serial  attacks  did  the  tem- 
perature go  above  100. 8°  F. 

Death  occurred  in  28^  per  cent,  of  the  status  cases; 
deaths  occurred  during  serial  attacks. 

In  his  conclusions  Bourneville  says:  "Isolated  at- 
tacks of  epilepsy  augment  the  central  temperature." 
The  only  logical  inference  we  can  draw  from  this 
statement  is  that  Bourneville  found  the  temperature 
increased  after  every  isolated  epileptic  seizure,  and 
nothing  exists  in  Bourneville 's  work  on  the  subject 
to  change  this  opinion. 

The  results  of  my  own  observations  agree  in  part 
only  with  those  of  Bourneville,  the  latter 's  work 
having,  in  my  opinion,  lost  much  of  its  value  through 
failure  to  classify  the  types  of  seizures  studied  and 
to  make  due  allowance  for  certain  physiologic  differ- 
ences in  temperature. 

After  making  due  allowance  for  diurnal  variation, 


BODY-TEMPERATURE.  267 

it  will  be  noted  that  40  per  cent,  would  be  the  lowest 
of  such  cases  showing  increased  temperature  after 
seizures,  and  70  per  cent,  the  highest,  making  the 
general  average  of  cases  of  all  types  showing  increased 
temperature  after  seizures  55  per  cent.,  the  difference 
in  the  results  obtained  by  Bourneville  and  by  the 
writer  being  45  per  cent.  The  views  of  such  eminent 
physiologists  as  Dalton,  Kirk,  Foster,  Landois,  and 
Stirling,  relative  to  the  part  played  by  muscular 
activity  in  creating  heat,  must  in  view  of  the  activity 
of  the  muscular  system  in  certain  cases  of  major 
epilepsy  have  great  weight  in  determining  the  cause 
of  the  heat  production  in  these  cases,  wholly  irrespec- 
tive of  any  influence  that  might  be  exerted  by  the 
heat  centers  in  the  brain. 

By  the  results  of  my  own  observations,  I  am  led  to 
believe  that  in  many  petit  mal  and  psychic  attacks 
in  which  muscular  activity  plays  so  small  a  part,  and  in 
which  the  temperature  is  often  increased  after  seizures, 
such  increase  is  due  to  a  disturbance  either  of  the  heat 
center  that  is  thought  to  exist  in  the  cortex  of  the 
brain,  or  of  the  center  or  centers  that  observers  believe 
have  been  located  in  the  corpus  striatum  and  optic 
thalamus. 

It  will  be  noted  that  subnormal  temperatures  fol- 
lowed epileptic  seizures  in  greater  proportion  after 
grand  mal  than  after  petit  mal  or  psychic  seizures,  the 
proportion  being  15  per  cent,  of  the  former  to  10  per 
cent,  of  the  latter,  and  while  I  agree  in  the  main  with 
Lemoine  as  to  the  cause  for  such  low  temperatures, 
when  he  says:  " Certain  cases  are  naturally  anomalous 
in  the  matter  of  temperature,  having  abnormally  low 
temperatures  in  health,"  I  do  not  believe  that  this 
explanation  is  altogether  sufficient,  but  that  there 
will  usually  be  found  to  exist  in  these  cases  some  chronic 
disease  or  general  asthenic  condition  of  long  standing 
that  lowers  the  stamina  and  vitality  of  the  individual. 


268  SEQUELAE    OF    EPILEPTIC    CONVULSIONS. 

All  that  has  been  said  by  Bourne ville,  Lemoine, 
and  others,  relative  to  the  high  temperature  in  status 
epilepticus.  is  confirmed  by  the  tabulated  results  in 
the  seventeen  cases  studied  by  the  writer. 

The  temperature  in  serial  attacks  runs  uniformly 
higher  than  in  isolated  attacks,  but  not  so  high  as  in 
status,  serial  attacks  occupying  midway  ground  as 
to  frequency,  severity,  temperature  elevations,  and 
mortality,  between  isolated  seizures  and  status  epi- 
lepticus. 

As  a  possible  factor  in  establishing  the  presence  of 
toxins  or  other  agencies  in  the  body  prior  to  and  pos- 
sibly causing  the  convulsions,  an  effort  was  made  to 
take  the  temperature  in  some  cases  before  the  attack 
when  the  aura  was  of  sufficient  length ;  but  it  was  done 
in  one  case  only,  and  in  this  the  heat,  beginning  two 
hours  before  the  fit,  ran  steadily  up  to  1020  F.,  when 
the  patient  passed  into  a  convulsion. 

Notwithstanding  the  apparent  lack  of  value  of  the 
feature  of  temperature  studies  in  epilepsy,  its  value 
in  differential  diagnosis,  as  we  shall  see  later  on,  may 
be  considerable. 

OTHER  EFFECTS  OF  EPILEPTIC  SEIZURES. 

Effects  on  the  Eye. — Among  the  more  specific  effects 
of  epileptic  convulsions,  dilatation  of  the  pupils 
occupies  a  prominent  place.  This  is  especially  true 
of  the  cortical  epilepsies  in  which  muscular  contrac- 
tion is  a  feature. 

I  fail  to  recall  a  single  genuine  epileptic  convulsion 
witnessed  in  which  both  pupils  were  not  more  or  less 
dilated — the  dilatation  in  some  instances  being  ex- 
treme. Two  reasons  are  assigned  for  this:  one,  that 
it  is  due  to  the  effects  of  asphyxiation;  the  other,  that 
it  is  due  to  the  direct  effects  of  the  convulsion  inde- 
pendent of  asphyxiation.  Probably  both  reasons  are 
correct  in  part. 


OTHER    EFFECTS.  269 

It  does  not  seem  that  asphyxia  can  be  the  one 
cause  in  all  cases.  I  have  personally  witnessed 
numbers  of  attacks  light  in  character  in  which  there 
was  absolutely  no  evidence  of  interference  with  respira- 
tion, yet  in  which  mydriasis  was  marked  early  in  the 
seizure. 

I  recall  several  cases  in  which  I  happened  to  have 
my  hands  on  both  wrists  of  the  patient.  The  fit  began 
by  gentle  contractions  in  the  muscles  of  the  hand 
and  arm,  and  I  observed  that  dilatation  of  the  pupils 
appeared  before  there  was  any  muscular  evidence  of  the 
fit  whatever ;  nor  was  there  in  any  of  these  cases  any 
fixing  of  the  chest  muscles  so  as  to  cause  asphyxia  in 
this  way.  This  would  seem  to  indicate  an  irritative 
disturbance  in  the  central  nervous  ocular  apparatus 
separate  and  distinct  from  the  respiratory  center. 

The  effect  of  the  attack  on  the  pupils  furnishes  a 
diagnostic  point  of  value  in  differentiating  epileptic 
convulsions  from  those  of  hysterical  origin. 

Equal  dilatation  is  the  rule  in  inorganic  epilepsies 
in  which  the  cause  is  in  the  cerebrum. 

If  the  epilepsy  is  due  to  local  organic  conditions  in 
the  brain,  the  dilatation  may  be  more  marked  on  one 
side  than  on  the  other,  not  only  during  the  attack  but 
during  the  interim. 

As  a  rule,  the  corneal  reflex  is  abolished  during 
epileptic  convulsions,  especially  when  the  attack  is 
severe  and  complete  loss  of  consciousness  is  an  early 
indication.  In  rare  cases  in  which  the  attack  is  rudi- 
mentary in  character,  the  cornea  retains  its  sensitive- 
ness to  some  extent  throughout  the  fit — paralleling 
the  effects  of  hysteria  in  this  respect. 

I  have  previously  spoken  of  what  is  termed  retinal 
epilepsy,  a  form  of  attack  made  up  by  sudden  blindness 
of  brief  duration — epileptic  amaurosis  it  is  called  by 
Hughlings-Jackson. 

Hemorrhagic   extravasations  into  the   conjunctivae 


270  SEQUELAE    OF    EPILEPTIC    CONVULSIONS. 

during  an  attack  have  also  been  mentioned.  These 
at  times  constitute  the  only  visible  sign  on  the  morn- 
ing following  a  nocturnal  attack,  though  they  are  more 
apt  to  be  present  in  conjunction  with  other  indications, 
such  as  a  sore  tongue,  headache,  malaise,  etc. 

Effects  on  the  Blood. — Chemical  pathology  is  not 
yet  a  sufficiently  elaborated  science  to  enable  us  to 
detect  blood  changes  in  epilepsy,  that  in  truth  may 
antedate  and  possibly  cause  the  convulsion,  as  well 
as  appear  as  the  result  of  the  fit.  At  this  time  little 
is  known  of  either. 

The  researches  of  Herter  along  this  line  have  been 
most  valuable,  embracing  the  study  of  the  toxicity  of 
the  blood  in  fifteen  cases  at  the  Craig  Colony.* 

In  these  instances,  Herter  tested  the  toxicity  of 
the  blood  after  grand  mat  seizures  and  again  after 
fifteen,  sixteen  and  a  half,  and  twenty-six  hours 
respectively.  In  one  case  the  blood  appeared  more 
toxic  at  the  second  bleeding  than  at  the  first;  in 
another,  more  toxic  at  the  first  bleeding  than  at  the 
second;  while  in  the  third  it  was  about  equally  toxic 
on  the  two  occasions. 

Blood  drawn  in  another  case  three  weeks  after  a 
seizure,  and  two  weeks  before  another,  and  infused 
into  a  dog  had  no  effects  other  than  those  due  to  the 
effusion  of  normal  blood  in  large  volume.  In  a  second 
case,  blood  drawn  fifteen  days  after  a  seizure  and 
several  days  before  another  was  infused  into  a  Java 
monkey  weighing  1200  grams,  145  c.c.  being  intro- 
duced. The  effects  were  those  expected  to  follow  a 
large  volume  of  normal  human  blood  thrown  into  the 
circulation,  death  being  referable  to  the  mechanical 
action  of  the  infused  blood.  Defibrinated  blood  was 
used  and  the  rate  of  infusion  uniformly  5  c.c.  per 
minute. 

*  "Toxic  Properties  of  the  Blood  in  Epilepsy,"  "Journal  of  Nervous 
and  Mental  Diseases,"  Vol.  xxvi,  p.  73,  1899. 


OTHER    EFFECTS.  271 

Herter  refers  to  the  scope  and  limitations  of  such 
investigations  as  being  great,  while  the  chance  for 
error  is  also  great;  and  he  gives  suggestions  of  value 
to  those  who  undertake  further  researches  along  a 
similar  line. 

Effects  on  the  Circulation. — In  284  cases  in  which 
the  pulse  beat  was  noted,  it  was  found  to  run  uniformly 
above  the  normal  in  189,  64  per  cent.  In  20  cases  it 
was  below  70;  in  74  cases,  from  70  to  80;  in  161  cases, 
from  80  to  100;  while  in  the  remaining  29  cases  it 
was  100  or  over. 

It  was  counted  in  every  instance  during  the  inter- 
paroxysmal  period,  the  patient  being  entirely  free 
from  any  immediate  epileptic  influence.  The  cause 
of  this  apparent  phenomenon  is  uncertain. 

A  rapid  heart  is  seen  most  commonly  as  a  result  of 
stimulation  by  drugs,  by  fear,  or  through  some  form 
of  fever.  None  of  these  is  applicable  in  this  case, 
except,  possibly,  in  rare  instances.  The  explanation 
may  eventually  be  found,  in  part  at  least,  in  the  re- 
peated and  powerful  depression  of  the  pneumogastric 
nerve. 

In  the  study  of  thirty-three  cases  to  determine  the 
relative  blood-pressure  as  near  to  the  convulsive  period 
as  possible,  and  as  remote  from  the  same  period  as 
possible,  the  results  given  in  the  table  on  page  272  were 
noted. 

To  summarize,  there  may  be  seen  in  this  table  an 
apparent  decrease  in  the  blood-pressure  just  before 
the  convulsive  period  in  eleven  cases,  and  an  increase 
in  twenty-one  at  the  same  period,  the  latter  being 
somewhat  more  marked  in  degree  than  the  former. 

Thus  it  may  be  noted  that  in  a  number  in  which  the 
reading  before  the  fit  ran  from  135  to  175,  twelve  hours 
later  it  had  dropped  from  20  to  60  points;  in  one,  15 ; 
in  one,  30;  in  two,  35  ;  in  one,  45  ;  in  one,  55  ;  and  soon. 
This   should  not  lead   us  to   suppose  that  increased 


272 


SEQUELAE    OF    EPILEPTIC    CONVULSIONS. 


blood-pressure  was  the  cause  of  the  attacks,  for  it  is 
yet  to  be  proved  that  such  pressure  was  not  the  result, 
in  part  at  least,  of  the  convulsion  and  not  the  cause. 
On  the  other  hand,  we  find  the  pressure  quite  often 
decreased  before  the  fit,  a  fact  that  may  be  as  signifi- 
cant as  the  former;  in  fact,  in  the  writer's  opinion, 
it  is  not  infrequently  more  so. 

BLOOD     PRESSURE     RECORDS     IN     THIRTY-THREE     CASES 
BEFORE    AND    AFTER    THE    CONVULSIVE    PERIOD. 


Hour 

at  which 

the  Attacks 

Age. 

are  most  Apt 

to  Occur. 

18 

7  to 

9  p.m. 

14 

" 

25 

" 

18 

" 

" 

26 

a 

" 

21 

14 

" 

18 

" 

15 

" 

" 

10 

18 

" 

13 

39 

20 

18 

n 

" 

18 

" 

ct 

28 

a 

u 

18 

9  to 

10  p.m. 

26 

" 

" 

43 

' ' 

" 

24 

22 

32 
42 
25 
25 

38 

24 
29 

25 

40 

34 
17 


Hour  at  which 
the  Blood-pres- 
sure is  Taken. 


Pressure 
Record 

before  the 
Convul- 
sive 
Period. 


Pressure 
Record 

at  the 
Hour 
most  Re- 
mote from 
the  Seiz- 
ure. 


105 

no 

95 

90 

140 

120 

"5 

120 

135 

100 

i°5 

125 

90 

145 

100 

100 

95 

90 

85 

So 

105 

"5 

no 

i°5 

150 

130 

120 

100 

130 

125 

160 

115 

125 

120 

108 

120 

135 

115 

155 

155 

135 

130 

120 

100 

125 

no 

150 

ii5 

175 

120 

140 

145 

144 

155 

95 

105 

105 

90 

13° 

"5 

155 

135 

i°5 

no 

130 

105 

Normal 
Pulse- 
rate. 


78 
96 

84 


7^ 
66 
90 
90 
90 
108 
66 


122 
72 
84 

120 
88 

84 
96 
So 
88 
76 
80 
104 
76 
88 
80 
76 
96 
76 


Pulse- 
rate  at 
the  Con- 
vulsive 
Period. 


80 
102 
108 
66 
66 
90 
96 
78 
66 
96 
72 
108 
72 
90 
84 
66 
90 
68 
76 
100 
76 
88 
88 
76 
68 
64 
88 
88 
84 
88 
88 
76 
76 


OTHER    EFFECTS.  273 

From  carefully  recorded  observations  in  58,873 
seizures  in  one  group  of  cases  at  the  Craig  Colony  in 
1902,  the  greatest  number  occurring  at  any  one  hour 
was  3628,  the  hour  being  3  a.m.,  the  time  at  which 
the  vitality  of  the  body  reaches  its  lowest  ebb. 

A  girl  of  thirteen  years,  whose  epilepsy  followed  a 
severe,  acute  attack  of  enterocolitis  in  her  sixth  year, 
and  who  never  had  an  attack  during  the  period  of  two 
years  she  was  under  my  observation,  save  when  she 
slept  either  by  night  or  by  day,  averaging  from  three 
to  five  or  more  seizures  each  night,  showed  a  blood- 
pressure  of  95  just  before  9  p.m.,  the  first  convulsive 
period  of  the  night ;  while  during  the  day  following  it 
was  from  125  to  130. 

It  is  evident  to  the  writer  that  low  pressures  are  the 
rule  in  some  cases  before  the  fit,  while  relatively  high 
pressures  are  the  rule  in  others. 

The  diagnostic  value  of  blood-pressure  in  epilepsy 
is  as  yet  even  more  in  its  infancy  than  in  other  con- 
ditions.    It  is  a  promising  field  for  investigation. 


18 


CHAPTER  X. 
DIAGNOSIS. 

The  Facies  Epileptica.  The  Distinguishing  Features  between  Epilepsy 
and  Hvsteria.  Alcoholism.  General  Paresis.  Syncope.  Toxemia.  Vertigo. 
Uremia.     Tetanus.     Simulation. 

I  have  already  so  fully  described  the  symptoms  of 
epilepsy  that  differential  diagnosis  only  will  be  con- 
sidered in  this  connection. 

The  diagnosis  of  epilepsy  as  a  rule  is  not  difficult.  If 
the  fit  can  be  witnessed  by  the  physician  from  the 
moment  the  first  symptom  appears  until  the  coma 
stage  is  over,  there  is  scarcely  a  case  in  which  there 
need  be  any  question  as  to  its  nature.  Without  this, 
errors  are  always  possible,  though  the  proportion  of 
cases  that  create  diagnostic  uncertainty  are  rare, 
representing  not  more  than  one  or  two  per  cent,  at 
most. 

The  only  way  to  guard  against  errors  in  this  respect 
is  to  acquire  clear  conceptions  of  the  numerous  forms 
of  the  disease  through  the  study  of  actual  cases. 

The  information  we  get  from  the  patient  or  his 
friends  is  not  infrequently  misleading,  and  it  is  not  safe 
to  base  a  diagnosis  on  it  in  all  cases.  Especially  are 
we  unable  to  rely  on  such  information  as  to  the  type 
of  the  disease,  which  is  often  as  important  as  the 
fact  of  its  presence.  Only  a  trained  observer  can 
make  such  distinctions. 

The  most  satisfactory  plan  is  to  place  the  patient 
under  the  care  of. a  skilled  attendant  who  knows  how 
and  what-  to  observe,  requiring  a  minute  record  to  be 
kept  of  every  convulsion  until  the  physician  can  fully 
satisfy  himself  as  to  the  exact  nature  of  the  disease. 

274 


THE    FACIES    EPILEPTICA.  275 

The  record  of  attacks  should  include  the  aura,  its 
nature  and  duration ;  the  order  of  invasion,  the  part  of 
the  body  in  which  the  convulsion  began,  the  order  of 
extension ;  the  part  of  the  body  or  group  of  muscles 
affected  one  after  the  other ;  the  stage  of  the  convulsion 
at  which  consciousness  was  impaired  or  lost;  and  if 
impaired  only,  to  what  extent;  the  condition  of  the 
pupils;  the  duration  of  the  period  of  tonic  contraction, 
of  the  period  of  clonic  contraction,  together  with  that 
of  coma  which  so  often  follows.  After-effects  should 
also  be  noted,  such  as  mental  disturbance,  headache, 
hemorrhagic  extravasations,  irritability,  thirst,  ex- 
haustion, post-epileptic  paralysis,  muscular  soreness — 
general  or  local — together  with  any  injury  or  loss  of 
function,  temporary  or  more  lasting,  occasioned  by 
the  attack. 

The  Facies  Epileptica. — The  condition  sometimes 
observed  in  epilepsy  and  termed  the  facies  epileptica 
has  a  very  limited  diagnostic  value,  for  the  reason  that 
it  is  never  present  save  in  chronic  cases  in  which  the 
identity  of  the  affection  is  already  fully  established. 

Facial  expression  is  produced  by  the  formation  of 
creases,  changes  in  the  contour  of  the  skin  and  under- 
lying structures,  due  to  muscular  and  trophic  altera- 
tions, to  the  patient's  habits  of  mind,  his  intellectual 
standard  and  temperament ;  and  in  disease  it  may  be 
changed  by  pathologic  processes  that  affect  other  and 
remote  parts  of  the  body. 

Epilepsy  may  affect  the  face  directly  or  indirectly 
in  several  ways :  (a)  Indirectly  by  covering  it  through 
medication  with  bromic  acne  which  is  more  commonly 
associated  with  epilepsy  than  any  other  disease;  (6) 
by  so  altering  the  patient's  mentality  in  many  cases 
as  to  make  the  reduction  in  intelligence  noticeable  in 
the  face.  The  countenance  of  the  epileptic  dement  is 
especially  heavy,  sodden,  and  devoid  of  every  aspect 
of  mind;    (c)  through  the  infliction  of  scars,  fractures 


276  DIAGNOSIS. 

of  the  nose  and  jaw,  burns,  bruises,  incised  wounds, 
and  other  injuries  received  during  convulsions. 

The  true  facies  epileptica,  the  only  form  possessing 
any  distinctive  worth  from  a  diagnostic  standpoint, 
is  that  made  up  of  the  trinity  of  results,  namely, 
epileptic  dementia,  scars,  and  bromic  acne.  These 
together  produce  a  facial  condition  that  cannot  be 
mistaken,  but  being  a  composite  picture  of  slow  forma- 
tion, is  of  little  or  no  value  in  the  diagnosis  of  recent 
epilepsy. 

Hysteria. — The  one  convulsive  disorder  more  apt  to 
be  mistaken  for  epilepsy  than  any  other  is  hysteria. 
The  statement  of  M.  Briquet,*  that  "hysterical  sub- 
jects are  apt  to  be  seized  from  time  to  time  with  spe- 
cial and  serious  conditions  which  appear  of  a  sudden 
and  usually,  after  a  short  duration,  disappear  as  quickly 
as  they  came,"  illustrates  the  points  of  similarity  in  a 
general  way  between  the  two  affections — both  are 
special  and  apparently  serious  conditions  at  the 
moment,  and  both  repeatedly  appear  and  disappear 
with  great  suddenness.  The  hysteric  state,  inde- 
pendent of  convulsive  attacks,  has  but  little  interest 
for  us  in  this  connection.  The  ground  for  confusion  is 
that  occupied  by  the  attacks  alone.  We  occasionally 
meet  with  cases  in  which  the  convulsions  of  hysteria 
alternate  with  the  convulsions  of  true  epilepsy,  the 
attacks  being  epileptic  to-day  and  hysteric  to-morrow. 
Under  such  circumstances,  the  diagnostic  view-point 
is  necessarily  altered — taking  its  color  from  the  type 
of  the  condition  present  at  the  moment. 

This  makes  it  desirable  for  the  physician,  in  the 
more  doubtful  cases  at  least,  not  to  be  hasty  in  giving 
his  opinion,  but  to  wait  until  he  has  opportunity  for 
witnessing  several  seizures,  or  of  having  their  nature 
reported  to  him  by  a  competent  observer. 

In   my  experience,  men   a   little   more   often   than 

♦Janet,  "The  Mental  State  of  Hystericals,"  1901,  p.  366. 


Plate  17. 


HYSTERIA. 


277 


women  have  hystero-epilepsy,  while  purely  hysterical 
convulsions  are  commoner  among  women. 

TABLE    SHOWING    MAIN    DIAGNOSTIC    POINTS    BETWEEN 
THE  CONVULSIONS   OF  HYSTERIA  AND   EPILEPSY. 


Age 


Exciting 
cause  . 


Warning      of 
attacks 


Mode  of  onset 


Type  of  con- 
vulsion . . . 


Conscious- 


ness 


Duration     of 
convulsion 


Posture 


Pupils  . 
Tongue 


Frothing      at 
mouth  .... 

Micturition.  . 
Defecation  . . 


Epilepsy. 

Common  before  puberty  and 
rare  as  a  recent  affection  after 
the  twentieth  year. 

Rarely  due  to  emotional  dis- 
turbance after  the  disease  is 
established. 

May  be  of  any  form.  Gen- 
erally affects  a  part  of  the  body 
first,  or  one  of  the  special 
senses,  or  the  aura  is  epigastric. 

Most  apt  to  be  sudden.  Epi- 
leptic cry  quite  frequent,  and  is 
usually  sharp  and  distinct,  the 
patient  falling  heavily  to  the 
ground  unconscious. 

Usually  begins  locally  with 
tonic  contractions  followed  by 
clonic  or  "jerking"  move- 
ments; rarely  rigidity  alone. 


In  the  majority  of  cases, 
lost;  always  in  the  classical 
grand  mal  attacks. 

On  an  average  from  one-half 
to  two  and  a  half  minutes  for 
the  active  period  only,  not  in- 
cluding the  periods  of  stertor 
and  coma. 

Body  postures  fixed  mainly 
by  the  flexors. 


Dilated  almost  without  ex- 
ception and  immobile. 
Frequently  bitten. 

Nearly  always  present,  espe- 
cially after  grand  mal  attacks. 

Involuntary  flow  of  urine 
common. 

Quite  common,  but  less  so 
than  urination. 


Hysteria. 
Very  uncommon  be- 
fore puberty. 

Often  due  to  emo- 
tional causes. 

Generally  preceded 
by  palpitation;  a  feeling 
of  malaise,  choking  sen- 
sation; special  senses  not 
affected. 

May  be  gradual,  the 
cry  long  drawn  out,  the 
fall  easy,  and  rarely  with 
injury  to  the  patient — 
injury  never  as  severe  as 
in  epilepsy. 

May  be  simple  rigid- 
ity, or  violent  general 
struggling.  No  clonic 
movements.  The  pa- 
tient is  tossed  about 
from  side  to  side,  the 
limbs  thrown  wildly 
about  in  the  air,  the 
head  turning  from  side 
to  side. 

Impaired  only  or  fully 
retained. 

Several  minutes  up  to 
several  hours. 


The  tendency  is  to  ex- 
tension; arc  de  cercle; 
peculiar  attitudes;  opis- 
thotonos. 

Mobile  and  active. 

Very  exceptionally  in- 
jured. 

Rarely  present. 

Never. 

Never. 


278 


DIAGNOSIS. 


Talking 


Necessity   for 
restraint  . . 


Temperature 


General  con- 
dition on 
termination 

Convulsive 
accidents 
and      post- 
convulsive 
states  


Epilepsy. 

No  vocal  sound  of  any  kind 
escapes  the  patient  during  an 
attack  of  classical  epilepsy, 
save  the  epileptic  cry  that  is 
variously  modified. 

To  prevent  the  patient  from 
suffering  bodily  injur}'  while  he 
is  unconscious. 

Increased  in  the  majority  of 
cases  from  half  a  degree  up  to 
2. 50  F.  or  more  immediately 
after  the  fit. 

Hebetude,  headache,  extreme 
fatigue,  muscular  soreness. 

Occasional  hemorrhagic  ex- 
travasations about  the  face  and 
neck.  Scars  from  injuries  or 
recent  wounds.  Mental  con- 
fusion. Automatism.  Re- 
flexes, superficial  and  deep,  di- 
minished. Drug  eruptions 
common.  The  fades  epileptica 
is  well  defined  in  some  chronic 
cases.  Post-epileptic  paralysis 
in  some  cases. 


Hysteria. 

Occasionally  a  con- 
fused medley  of  words, 
groans,  or  somewhat  ir- 
rational conversation  is 
indulged  in. 

To  control  more  or 
less  purposeful  violence 

Never  increased. 


Ending  more  prompt. 
Patient  suffers  little  dis- 
comfort. 

No  hemorrhagic  ex- 
travasations ;  reflexes 
not  impaired;  mental 
poise  regained  at  once; 
no  eruption  due  to 
drugs.  The  facies  epi- 
leptica never  present. 
Wounds  never  received 
during  the  attacks. 
Post-epileptic  paralysis 
never  present. 


The  foregoing  diagnostic  points  apply  on  the  one 
side  more  particularly  to  the  convulsions  of  major 
hysteria.  The  points  of  distinction  between  the  con- 
vulsive phenomena  of  epilepsy  and  those  of  hysteria 
lie  wholly  along  two  lines :  psychologic  and  motor.  In 
hysteria,  psychologic  disturbances  predominate  in 
range  though  not  in  intensity;  in  epilepsy  motor  dis- 
turbances, while  usually  less  diversified  in  character, 
are  more  pronounced  in  degree. 

We  must  not  fail,  however,  to  recognize  the  ex- 
tremely complex  nature  of  the  phenomena  that 
hysterical  subjects  present,  for  classic  manifestations 
of  this  disease  are  not  constant,  and  especially  is  this 
true  of  the  hysterias  complicated  with  epilepsy. 

Our  greatest  difficulty  will  be  experienced  in  diag- 
nosticating the  convulsions  of  hysteria  major  from 
true  epileptic  convulsions,  so  that  we  need  scarcely 
consider  hysteria  in  any  other  form,  unless  we  should 
be  occasionally  perplexed  in  differentiating  the  motor 
disturbances  common  to  both  and  which  are  especially 


ALCOHOLISM.  279 

likelv  to  occur  in  motor  epileptics  whose  disease  is 
of  long  standing. 

Fere  has  shown  that  both  centripetal  and  centrifugal 
transmission  in  hysterical  subjects  are  retarded,  which 
causes  a  slackening  of  voluntary  movements,  necessi- 
tating a  longer  time  for  the  performance  of  required 
movements.  The  same  is  true  of  some  cases  of  chronic 
epilepsy,  especially  when  the  disease  is  largely  motor 
in  character.  The  voluntary  movements  of  hysterical 
subjects  are  also  marked  by  indecision  and  lack  of 
direction.  Both  of  these  likewise  apply  to  the  move- 
ments of  chronic  motor  epileptics,  and  in  them  become 
even  more  extreme  than  in  hysteria. 

There  is  another  analogous  condition  essentially  de- 
pendent upon  the  same  causes  operative  in  the  above. 
Movements  of  all  kinds  are  simplified  in  character, 
both  in  hysteria  and  in  epilepsy,  as  shown  by  the 
fact  that  neither  are  competent  to  perform  complex 
acts  which  necessitate  the  execution  of  several  different 
movements  at  the  same  time.  Janet  has  sought  to 
show  that  hysterical  subjects  can  consciously  perform 
but  one  movement  at  a  time;  a  limitation  that  also 
applies  to  chronic  epileptics  generally  during  the 
inter-paroxysmal  period. 

All  these  conditions,  namely,  slackening  of  volun- 
tary movements,  indecision,  and  lack  of  direction,  and 
the  ability  to  perform  any  but  simplified  movements, 
indicate  the  ravages  of  degenerative  diseases,  and  while 
possessing  great  scientific  interest,  are  of  but  little 
value  when  we  come  to  distinguish  one  convulsive 
disease  from  the  other. 

Alcoholism. — Simple  intoxication  uncomplicated  by 
convulsions  could  be  mistaken  for  epilepsy  only  during 
the  coma  period  which  is  similar  in  some  respects  in  the 
two  conditions.  The  fact  that  the  patient  in  alcoholic 
coma  can  usually  be  aroused  to  some  extent  and  the 
presence    of    the    characteristic    alcohol    breath    are 


280  DIAGNOSIS. 

usually  sufficient  to  exclude  the  profound  state  of 
coma  that  follows  immediately  upon  an  epileptic  fit. 

In  severe  cases  of  alcoholism  in  which  there  happens 
to  be  a  fracture  of  the  skull  with  deeper  coma,  the 
diagnosis  is  not  easy.  In  such  cases  the  .physician 
may  save  himself  some  humiliation  by  not  expressing 
a  fixed  opinion  until  he  has  had  ample  opportunity  for 
observation. 

When  epilepsy  arises  as  the  result  of  either  acute 
or  prolonged  alcoholic  indulgence,  it  is  identical  in 
every  respect  to  the  epilepsies  induced  by  other  causes, 
even  though  we  may  call  acute  alcoholic  convulsions 
symptomatic  only.  In  such  cases  less  is  to  be  gained 
through  diagnostic  distinctions  than  through  the  study 
of  etiology,  upon  which  the  treatment  must  largely  be 
based. 

When  one  or  more  convulsions  follow  excessive 
drinking,  and  at  no  other  time,  the  patient  should 
understand  that  they  indicate  acute  poisoning  of  a 
most  serious  kind,  and,  unless  they  are  checked,  will 
sooner  or  later  pass  into  the  essential  disease,  so  far  as 
ultimate  results  are  concerned. 

Not  infrequently  convulsions  due  to  drink  continue 
after  the  drink  habit  is  abandoned;  in  fact,  this  is 
more  often  the  case  than  not. 

After  all,  the  chief  point  of  distinction  between  most 
alcoholic  convulsions  and  those  of  essential  epilepsy,  so 
far  as  the  ultimate  results  are  concerned,  lies  in  the 
relationship  in  point  of  time  between  the  indulgence 
and  the  convulsion.  When  convulsions  originally  due 
to  alcohol  begin  to  appear  independent  of  the  intoxi- 
cated state,  we  may  no  longer  regard  them  as  sympto- 
matic only,  but  as  indicative  of  a  profounder  state  of 
brain  instability. 

General  Paresis. — The  chief  point  of  similarity 
between  epilepsy  and  general  paresis  is  found  in  the 
epileptiform    convulsions    that    characterize    certain 


GENERAL    PARESIS.  2»I 

periods  of  the  latter.  Chase  *  speaks  of  a  woman  who 
was  treated  for  four  years  with  the  bromids  for  epilepsy, 
and  who  was  later  thought  to  have  hysterical  convul- 
sions, but  she  proved  finally  to  be  a  paretic.  An 
express  driver  mentioned  by  Folsom  had  epileptiform 
seizures  for  five  years,  when  he  became  so  forgetful 
and  inattentive  that  he  was  discharged.  Later  he 
developed  paresis. 

In  rare  instances  the  two  diseases  may  coexist, 
either  antedating  the  other.  Chase  mentions  three 
such  cases,  one  observed  by  Christian,  one  by  Mark- 
ham,  and  one  by  himself.  The  latter  was  a  woman, 
twenty-eight  years  old,  whose  father  and  uncle  were 
epileptic,  while  she  herself  had  suffered  from  epilepsy 
from  the  ninth  to  her  twelfth  year.  She  ran  a  typical 
paretic  career,  dying  of  paresis  within  eighteen  months. 
Here  there  was  a  period  of  sixteen  years  between  the 
cessation  of  the  epilepsy  and  the  development  of 
paresis,  and  it  might  be  difficult  to  establish  any 
etiologic  relationship  between  the  two. 

Several  men,  ranging  in  age  from  forty-seven  to 
fifty-five  years,  have  come  under  observation  at  the 
Colony,  in  whom  the  epilepsy  was  due  to  alcohol, 
and  all  presented  quite  distinct  physical  symptoms 
of  paresis  for  years,  though  none  were  classed  as 
paretic.  They  were  under  observation  from  five  to 
eight  years. 

M.  J.  Q.,  a  male  epileptic,  entered  the  Colony  in 
July,  1902.  Age,  forty-one  years;  history  of  epilepsy 
for  four  years.  Positive  syphilitic  infection  could  not 
be  proved,  though  it  was  strongly  suspected.  The 
patient  had  been  a  steady  though  mild  drinker  for 
years.  His  family  history  was  not  good.  In  nine 
months  at  the  Colony  he  had  forty-seven  seizures,  four 
of  them  occurring  at  night;  none  were  grand  mal;  all 
were  mild,  a  few  being  psychic  and  not  lasting  more 
than  four  or  five  seconds.     Several  like  these  occurred 

*  "General  Paresis,"   1902,  p.  34. 


282  DIAGNOSIS. 

in  the  writer's  presence.  The  pupils  were  dilated  at 
each  attack,  the  dilatation  being  more  marked  in  the 
left  eye  than  in  the  right.  Reaction  to  light  in  the 
right  eye  had  been  slow  for  several  months.  He  was 
depressed  most  of  the  time,  though  occasionally  would 
rouse  up  with  some  spirit  and  declare  himself  capable 
of  again  taking  up  his  work  as  a  life  insurance  agent. 
A  history  of  some  exaltation  at  the  beginning  of  his 
trouble  was  obtained. 

His  paretic  symptoms  showed  most  in  his  speech, 
writing,  and  in  general  muscular  tremors.  The  latter 
were  especially  marked  about  the  lips,  face,  and  hands. 
He  also  showed  at  times  a  marked  facial  paresis  that 
appeared  independent  of  his  attacks.  The  specimens 
of  his  writing  at  the  beginning  of  his  trouble  and  four 
years  later,  and  here  presented,  show  a  very  pronounced 
difference. 

Several  alienists  who  examined  him  in  June,  1903, 
twelve  months  after  he  came  to  the  Colony,  pronounced 
him  a  paretic,  running  a  tardy  course.  It  was  difficult 
to  differentiate  some  of  his  epileptic  attacks  from  the 
epileptiform  attacks  of  paresis.  As  a  rule,  the  former 
were  more  general,  the  latter  local  in  their  expression, 
and  they  did  not  produce  automatism  like  true  epilepsy. 

Another  point  in  the  differential  diagnosis  between 
the  two  diseases  is  that  the  epileptic  irritability  of 
temper  with  strong  impulses  to  violence  differs  radi- 
cally from  the  placid,  good-natured  demeanor  of  the 
paretic  while  he  is  passing  through  the  stage  of  his 
disease  during  which  epileptiform  phenomena  are  most 
likely  to  appear.  In  epilepsy,  too,  the  inter-paroxys- 
mal period  is  usually  free  from  evidences  of  disease, 
while  in  paresis  this  is  not  the  case.  Paretic  symptoms 
are  continuous. 

Fibrillary  tremors  about  the  mouth,  face,  tongue, 
and  fingers  in  epilepsy  adhere  closely  to  the  seizure 
period,  generally  appearing  just  before  the  fit  and 
subsiding  completely  after  it.  In  general  paresis  dis- 
turbances of  motility  persist  continuously,  and  steadily 
grow  more  pronounced. 


Plate  iS. 


A  case  of  paresis,  with  right  facial  paralysis,  in  which  the  convulsions 
so  closely  simulated  those  of  true  epilepsy  as  to  be  mistaken  for  them  for 
a  year,  when  other  paretic  symptoms  became  more  pronounced.  Con- 
vulsions first  appeared  during  the  thirty-eighth  year,  and  were  alternately 
grand  mal  and  psychic,  the  latter  greatly  predominating. 


SYNCOPE.  283 

Some  motor  epileptics  in  time  acquire  the  drawling, 
hesitating  speech  common  to  paretics,  but  they  show- 
nothing  else  corroborative  of  the  more  fatal  disorder. 
Above  all,  the  epileptic  never  exhibits  the  expansive 
ideas  that  so  often  distinguish  the  mental  enfeeblement 
of  the  paretic. 

Paresis  also  rarely  occurs  before  adult  life,  few 
cases  arising  under  eighteen  or  twenty,  while  epilepsy 
is  essentially  a  disease  of  early  life,  more  than  three- 
fourths  of  all  cases  occurring  before  the  twentieth  year. 

Notwithstanding  the  various  points  of  differentiation, 
we  may  occasionally  meet  with  cases  in  which  the  best 
aid  to  diagnosis  is  time,  a  study  of  the  patient's  ante- 
cedents being  in  the  meanwhile  of  the  greatest  value. 

Syncope.— Ordinary  epileptic  convulsions  and  syn- 
copal attacks  are  not  likely  to  be  mistaken  one  for 
the  other.  There  may  be  some  confusion,  however, 
in  making  a  distinction  between  syncopal  attacks  that 
cause  more  or  less  prolonged  loss  of  consciousness, 
and  some  minor  attacks  of  epilepsy  that  do  not  involve 
the  motor  side.  The  distinction  of  these  from  fainting 
attacks  rests  first  on  the  absence  of  obvious  exciting 
influences.  Syncope  is  most  often  witnessed  in  feeble 
persons  and  under  conditions  of  mental  emotion, 
overexertion,  heated  rooms,  during  exhausting  dis- 
eases, diarrhea,  severe  abdominal  pains,  and  heart 
disease. 

The  "faints"  of  epilepsy  occur  without  warning,  in 
the  strong  as  well  as  in  the  feeble;  they  come  on  at 
all  times  and  under  all  circumstances.  They  do  not 
require  an  exciting  cause,  and  more  often  do  not 
disturb  body  posture,  not  even  causing  the  eyes  to 
close,  a  phenomenon  never  witnessed  in  simple  syn- 
cope. In  the  latter  the  pulse  is  apt  to  be  feeble  and 
often  fails  completely  just  before  the  faint.  In  epilepsy 
it  may  be  slightly  lowered  in  frequency,  though  the 
volume  remains  good. 


284  DIAGNOSIS. 

Either  condition  may  be  preceded  by  pallor  of  the 
face,  while  slight  flushing,  which  is  never  present  in 
syncope,  occurs  at  the  beginning  of  some  epileptic 
' '  faints. ' '  The  loss  of  consciousness  in  this  form  of  epi- 
lepsv  is  sudden  and  complete,  while  some  confusion 
and  headache  follow  its  restoration.  In  syncope  the 
loss  of  consciousness  may  be  preceded  by  nausea  and 
a  feeling  of  faintness.  Xor  is  there  a  distinct  aura 
before  simple  faints,  such  as  often  occurs  in  connection 
with  the  special  senses  in  epilepsy.  Such  aura  take 
a  wide  range  and  include  many  of  the  forms  heretofore 
described  under  psychic  and  petit  mat  epilepsy. 

Micturition,  which  occurs  frequently  in  epilepsy,  is 
unknown  in  syncope.  Automatic  acts  after  the  latter 
are  never  noticed,  while  they  are  more  often  present 
than  absent  after  the  former.  One  of  the  simplest 
and  most  common  of  such  acts  in  this  state  is  that 
of  undressing,  the  patient  often  removing  part  of  his 
clothing  before  he  becomes  conscious  of  what  he  is 
about. 

In  addition  to  these  distinguishing  symptoms,  the 
epileptic  often  shows  other  severe  manifestations  of 
his  disease. 

Toxemic  Convulsions. — I  have  previously  discussed 
under  etiology  the  convulsions  due  to  alcohol,  lead, 
and  certain  blood  states  associated  with  kidney  dis- 
ease. All  of  these  may  cause  convulsions  epileptoid 
in  character  and  stop  at  that,  or  they  may  be  continued 
into  the  establishment  of  genuine  epilepsy  (so  far,  at 
least,  as  clinical  manifestations  and  ultimate  results 
go)  after  the  apparent  removal  of  the  primary  cause. 
Witness  the  forms  of  epilepsy  that  follow  scarlatinal 
nephritis,  those  that  follow  the  use  of  alcohol  years 
after  its  consumption  has  stopped,  and  those  that 
follow  a  single  poisoning  of  the  system  with  lead  (as 
in  the  case  cited  in  the  chapter  on  Etiology).  It  is 
only  when  these  three  causes  are  active  in  the  pro- 


VERTIGO.  285 

duction  of  the  first  few  convulsions  that  our  attention 
in  differential  diagnosis  is  required. 

When  alcohol  is  the  cause,  it  is  generally  sufficiently 
obvious ;  the  convulsions  appear  after  alcoholic  ex- 
cesses, and  possess  nothing  to  distinguish  them  from 
ordinary  epilepsy,  save  the  relationship  between  cause 
and  effect. 

Uremic  convulsions  are  generally  accompanied  by 
other  signs  of  the  blood  state  present,  while  the  diag- 
nosis can  be  made  sure  of  by  a  thorough  examination 
of  the  heart  and  kidneys.  In  most  of  these  cases  the 
pulse  is  tense  and  full,  the  heart  hypertrophied. 

Convulsions  due  to  saturnine  intoxication  are  not 
difficult  of  detection.  The  accompanying  physical 
signs,  such  as  wrist  drop,  colicky  pains,  the  blue  line  on 
the  gums,  and  the  patient's  occupation,  are  generally 
sufficient  to  establish  their  character.  At  first  they 
are  regarded  as  symptomatic  only;  later,  like  other 
toxemic  convulsions,  they  may  result  in  established 
epilepsy. 

"  It  is  important  to  remember,"  says  Gowers,  "that 
convulsions  from  lead  and  alcohol  may  persist  after 
the  original  cause  has  ceased  to  operate,  and,  in  such 
cases,  the  effect  of  that  cause  and  of  the  repeated 
convulsions  has  apparently  been  to  excite  in  the  brain 
a  pathologic  state  similar  to  that  which  exists  in 
simple  epilepsy." 

Vertigo. — Occasionally  difficulty  may  be  experienced 
in  diagnosing  aural  or  auditory  vertigo,  when  severe  in 
form  (Meniere's  disease),  from  lighter  forms  of  epilepsy. 

As  a  rule,  aural  vertigo  is  associated  with  laby- 
rinthine disease  of  a  pronounced  form,  tinnitus,  and 
nerve  deafness,  which  may  be  slight  or  severe,  of  recent 
origin  or  long  standing.  Disturbances,  such  as  ringing 
in  the  ears,  in  such  cases  are  constant  and  are  not 
confined  to  the  seizure  period  as  in  epilepsy. 

As  a  rule,  the  onset  of  aural  vertigo  is  sudden,  but 


286  DIAGNOSIS. 

it  may  be  slow  in  passing  away,  whereas  in  epilepsy 
the  symptoms  disappear  at  once.  A  patient  may 
suffer  from  both  aural  vertigo  and  epilepsy  (Gowers). 
In  some  cases  in  which  there  is  considerable  brain 
instability  and  the  origin  of  the  disease  labyrinthine, 
the  attacks  may  so  closely  simulate  those  of  true 
epilepsy,  even  to  the  loss  of  consciousness,  as  to  create 
much  confusion. 

Tetanic  convulsions  are  not  apt  to  be  mistaken  for 
epilepsy  of  the  commoner  types.  They  may  in  very 
rare  instances  be  confounded  with  epileptic  attacks 
that  are  tetanoid  in  nature,  and  which  have  been 
described  with  sufficient  fullness  in  Chapter  IV  under 
Seizure  Types  to  render  further  reference  to  them  in 
this  connection  unnecessary.  As  a  rule,  tetanic  con- 
vulsions are  far  more  severe  in  character  and  of  longer 
duration  than  those  of  tetanoid  epilepsy. 

There  is  also  usually  a  history  of  injury  in  tetanus, 
such  as  running  a  nail  in  the  foot,  while  the  jaws  in 
tetanus  remain  locked  for  a  much  longer  time.  The 
history  of  the  case  adds  points  of  value  in  the  differen- 
tial diagnosis  of  the  two  affections. 

Simulation. — Epileptic  convulsions  are  occasionally 
simulated  by  two  classes  for  one  of  two  purposes: 
either  by  criminals  to  escape  punishment  for  crime, 
or  by  beggars  for  personal  gain.  The  former  simulate 
attacks  at  opportune  moments  when  observers  may  be 
led  to  believe  that  they  are  victims  of  disease;  the 
latter  feign  epileptic  attacks  in  a  crowd,  or  in  selected 
places  where  they  are  most  apt  to  excite  the  sympathy 
of  those  they  would  deceive. 

It  is  exceedingly  difficult  to  practise  simulation  in 
a  manner  to  deceive,  for  any  length  of  time,  one  trained 
in  the  observance  of  epileptic  phenomena. 

The  .first  point  in  favor  of  the  genuineness  of  the 
attack  is  the  previous  existence  of  the  disease.  If  this 
can  be  proved  conclusively,  it  is  always  difficult  to 
say  that  any  subsequent  attack  is  not  epileptic. 


SIMULATION.  287 

The  first  point  in  favor  of  simulation  is  the  presence 
of  a  motive.  Given  this,  it  is  always  well  to  question 
the  nature  of  the  attack. 

Due  attention  to  the  following  points  of  distinction 
will  generally  enable  us  to  say  whether  the  attack  is 
spurious  or  genuine.  The  simulator  chooses  the  time 
and  place  for  an  attack;  the  epileptic  does  not.  The 
simulator  seldom  falls  in  a  manner  to  suffer  injury, 
while  the  epileptic  is  frequently  injured,  often  very 
severely.  I  have  previously  called  attention  to  the 
frequency  with  which  scars  are  met  with  in  the  epi- 
leptic. These  may  be  found  to  a  limited  extent  in 
impostors,  but  they  are  rare  and  seldom  if  ever  met 
with  about  the  face,  which  is  the  favorite  site  for  them 
in  the  true  disease. 

In  simulated  attacks  the  pupils  are  not  dilated; 
the  urine  and  feces  not  voided;  the  tongue  seldom 
bitten ;  the  face  and  neck  never  covered  with  petechial 
discolorations ;  the  epileptic  cry  is  absent;  the  sen- 
sitiveness of  the  cornea  is  not  impaired;  and  there  is 
never  any  degree  of  post-epileptic  or  exhaustion 
paralysis,  or  any  increase  in  body-temperature.  The 
simulator,  in  closing  his  fist  during  the  supposed  attack, 
leaves  the  thumb  outside  the  fingers,  and  if  the  fingers 
are  forcibly  opened  he  will  contract  them  again.  In 
the  epileptic  hand,  the  thumb  is  across  the  palm  and 
held  down  by  the  overlapping  fingers.  In  epilepsy 
the  pupils  are  nearly  always  dilated,  and  immobile 
to  light ;  urine  and  feces  are  frequently  voided ;  the 
tongue  is  very  frequently  bitten ;  the  face  and  neck  in 
some  cases  are  covered  with  a  petechial  eruption; 
the  epileptic  cry  is  often  heard;  the  corneal  reflex  is 
generally  abolished,  and  there  is  not  infrequently  some 
marked  result  of  the  fit,  such  as  paralysis,  automatism, 
mental  disturbance,  and  aphasia,  and  in  more  than  half 
the  cases  there  is  an  elevation  in  body-temperature, 
ranging  from  .5  to  2.50  F. 


288  DIAGNOSIS. 

The  simulator  may  cause  his  face  to  flush  or  become 
cyanosed  through  fixation  of  the  chest  muscles,  and 
he  can  produce  a  bloody  froth  by  biting  the  tongue 
and  placing  a  piece  of  soap  in  his  mouth ;  but  he  can- 
not cause  the  facial  pallor  which  is  witnessed  before 
almost  every  epileptic  attack,  in  which  flushing  is 
extremely  rare. 

Another  valuable  point  of  differentiation  lies  in 
the  tone  and  degree  of  muscular  contractions.  The 
simulator  can  reproduce  tonic  better  than  clonic 
contractions.  By  firmly  grasping  the  bare  forearms 
of  the  patient  during  the  clonic  period  of  contraction, 
we  will  find  that  in  true  epilepsy  the  contractions  are 
short,  sharp,  regular,  electric-like,  and  powerful  in 
degree,  as  compared  with  those  produced  at  will. 
Here  they  are  irregular,  mild  in  degree,  and  wholly 
lacking  in  the  sharpness  and  force  that  characterize 
the  former. 

Heller  has  suggested  that  during  a  suspicious  attack 
firm  pressure  be  exercised  on  some  group  of  muscles, 
such  as  those  of  the  thigh.  After  a  time  the}^  will 
relax,  and  if  an  attempt  is  then  made  to  flex  the  limb 
the  simulator  will  contract  the  muscles  again. 

In  simulated  attacks,  as  in  hysteria,  pressure  over 
the  supraorbital  nerve  will  cause  the  patient  to  show 
distress,  while  in  the  epileptic  it  produces  no  result. 

Hughlings-Jackson  first  pointed  out  the  loss  of 
knee-jerk  and  ankle-clonus  after  severe  epileptic 
attacks, — symptoms  which  cannot  be  feigned. 

MacDonald  reports  in  the  case  of  Clegg,  who  was 
arrested  for  crime  and  known  as  the  "  dummy  chucker,' ' 
an  instance  in  which  skilled  observation  detected 
simulated  convulsions  so  nearly  like  the  true  disease 
that  they  long  deceived  numerous  physicians  and 
prison  officials.  (See  Hamilton's  "System  of  Legal 
Medicine,"  Vol.  n,  p.  404.) 

With  our  rapidly  advancing  knowledge  of  epilepsy, 


SIMULATION.  289 

it  becomes  more  difficult  for  impostors  to  success- 
fully simulate  the  true  disease,  while  the  cultivation 
and  careful  training  of  professional  beggars  and  crimi- 
nals to  practise  simulation  grows  constantly  less. 


J9 


CHAPTER  XI. 
PROGNOSIS. 

Recovery  Under  Treatment.  Spontaneous  Recovery.  Improvement. 
Favorable  Indications.  The  Prognostic  Value  of  Aura.  The  Danger  to 
Life.     Influence  on  Longevity. 

The  prognosis  in  epilepsy  is  more  difficult  to  decide 
than  any  other  disease,  insanity  not  excepted.  It 
involves  not  only  the  question  of  curability,  but  the 
forecasting  of  numerous  other  conditions  the  patient 
may  attain.  These  differ  in  different  types  of  the 
disease  and  in  different  individuals  of  the  same  type; 
so  that  the  question  of  prognosis  covers  the  follow- 
ing: (a)  recovery  under  treatment;  (6)  spontaneous 
recovery;  (c)  arrest  of  attacks;  (d)  improvement; 
(e)  the  probable  effects  of  the  disease  on  the  mind; 
(/)  its  liability  to  a  fatal  termination ;  (g)  its  influence 
on  longevity. 

RECOVERY  UNDER  TREATMENT. 
Hippocrates*  wrote  concerning  the  Sacred  Disease: 
"If  it  attacks  little  children,  the  greater  number  die. 
.  .  .  .  If  youths  and  young  adults,  recovery 
may  take  place ;  but  there  is  danger  of  its  becoming 
habitual,  and  even  increasing  if  not  treated  by  suit- 
able remedies.  Such  is  also  the  case  when  it  attacks 
young  children.  .  .  .  When  it  attacks  people  of 
advanced  years,  it  often  proves  fatal.  .  .  .  When 
a  person  has  passed  the  twentieth  year  of  life,  the 
disease  is  not  apt  to  seize  him  unless  it  has  become 
habitual  from  childhood.  When  the  disease  has 
prevailed  for  a  length  of  time,  it  is  no  longer  curable." 

*  "Sydenham  Society's  Translation,"  Vol.  II,  p.  850  et  seq. 
290 


RECOVERY  UNDER  TREATMENT.         291 

Ancient  Greek  and  Roman  physicians  appear  to 
have  taken  a  more  generally  favorable  view  of  the 
malady  than  has  been  the  custom  in  more  recent 
times. 

It  is  apparent  that  we  owe  the  gloomy  view  of  the 
prognosis  largely  to  the  French  physicians  in  the 
earlier  decades  of  the  last  century.*  Later  came 
more  favorable  reports  from  Herpin  (1852)  and 
Trousseau  (1861)  in  France,  and  Russell  Reynolds 
(1861)  in  England. 

As  far  back  as  1 778-1 780,  Tissot  almost  alone 
stated  that  he  had  cured  a  great  number  of  epileptics, 
and  nearly  a  century  later  Russell  Reynolds  corrob- 
orated Tissot' s  favorable  opinion.  Both  believed  that 
much  could  be  done  toward  the  arrest  of  the  disease. 

In  the  pre-bromid  days  it  is  interesting  to  recall 
the  high  percentage  of  so-called  cures  which  have  been 
recorded.  Thus,  Hufeland  stated  that  a  cure  was 
effected  in  5  per  cent,  of  his  cases ;  Russell  Reynolds,  in 
10  per  cent.;  Trousseau  effected  a  cure  in  20  out  of 
150  cases,  13  per  cent.;  and  Herpin  was  perhaps 
justified  in  his  sanguine  belief  that  he  effected  a  cure 
in  19  out  of  38  cases,  50  per  cent.   (Turner ).f 

The  same  writer  states  that  the  almost  universal 
administration  of  the  bromids  since  their  introduc- 
tion in  1857  has  in  no  way  modified  the  variability 
of  the  results  obtained.  Some  of  the  more  recent 
writers  give  the  following  proportions  of  cures : 

Nothnagel,  from 4    to  5  per  cent. 

Laehr 6 

Ackermann 7.6 

Dana 5    to  10 

Wildermuth 8.5 

Habermas 10.3 

Alt 12.5 

*  Maissonneuve,  1803;  Pinel,  1818;  Esquirol,  1838;  Valliex,  1851;  and 
others. 

t  Turner,  "A  Statistical  Inquiry  into  the  Prognosis  and  Curability  of 
Epilepsy,"  "Medico-Chirurgical  Transactions."  London,  Vol.  lxxxvi, 
1903. 


292  PROGNOSIS. 

"The  introduction  of  bromid  of  potassium  into 
therapeutics  has  remarkably  improved  the  prognosis. 
Absolute  recovery  persisting  ten,  fifteen,  or  twenty 
years  is  rare,  but  amelioration  is  frequent"    (Fere). 

"The  facts  relating  to  the  cure  of  the  disease  are 
extremely  meagre.  Few  cases  can  be  watched  suffi- 
ciently long  to  enable  a  cure  to  be  confidently  affirmed. 
Moreover,  the  cases  in  which  the  best  results  are 
obtained,  in  which  no  more  fits  occur,  are  precisely 
those  that  are  never  heard  of  again.  Such  cases  are, 
I  am  sure,  far  more  common  than  is  imagined" 
(Gowers) . 

The  fewer  apparent  cures  under  the  bromid  period 
may  be  accounted  for  in  a  large  measure  by  greater 
precision  in  diagnosis.  The  later  writers  excluded 
from  their  statistics  all  symptomatic  epilepsies,  noting 
cases  of  the  idiopathic  disease  only.  It  is  well  known 
that  the  latter  are  far  less  curable  than  the  former. 

In  his  admirable  monograph  on  the  subject  (op. 
cit.)  G.  Alden  Turner  asks:  "Is  there  a  cure  for  epi- 
lepsy?" He  answers  in  the  affirmative,  and  his  sum- 
mary and  conclusions  are  so  carefully  drawn  and  are 
of  such  value  that  I  give  them  in  substance  in  the 
following : 

Turner  studied  366  cases  from  out-patient  records 
of  the  National  Hospital  for  the  Paralyzed  and  Epi- 
leptic (London),  excluding  all  save  those  classed  as 
idiopathic  and  those  in  which  the  patients  had  not 
been  under  treatment  at  least  two  years. 

They  were  divided  into  three  series  according  to 
the  manner  in  which  they  responded  to  treatment: 
arrested,  improved,  and  confirmed.  A  family  history 
was  found  more  frequently  among  those  classed  as 
confirmed,  but  an  hereditary  history  was  not  found  to 
militate  against  the  prospects  of  arrest  or  improve- 
ment of  the  disease  in  any  given  case. 

The  age  at  the  onset  of  the  disease  and  the  duration 


RECOVERY  UNDER  TREATMENT.         293 

of  the  malady  was  found  to  influence  the  prognosis 
to  a  great  extent. 

Improvement  or  cure  is  much  more  likely  to  be 
attained  during  the  first  five  than  during  the  second 
five  years,  although  some  may  be  arrested  after 
twenty  or  thirty  years. 

Epileptics  subject  to  daily  or  weekly  attacks  are 
least  likely  to  be  benefited,  while  those  who  go  longest 
without  a  fit  are  most  likely  to  be  cured  or  improved. 
Major  attacks  are  more  amenable  to  treatment  than 
minor  ones,  next  coming  major  and  minor  combined, 
then  minor  alone. 

Long  remissions  induced  by  successful  treatment. 
or  occurring  spontaneously,  are  not  unusual,  and  have 
a  favorable  prognostic  value,  but  are  not  synonyms 
of  cure. 

' '  From  the  collected  statistics  a  period  of  arrest  for 
at  least  nine  years  has  been  fixed  as  the  basis  upon 
which  a  cure  of  epilepsy  may  be  established.  With  this 
definition  of  a  cure,  I  regard  10.2  per  cent,  of  epileptics 
as  curable"   (Turner). 

It  would  be  unreasonable  to  argue  that  the  length 
of  time,  which  Turner  has  fixed  upon  that  should 
elapse  before  a  cure  is  pronounced,  is  not  long  enough. 
It  should  satisfy  the  most  skeptical  among  those  who 
may  not  believe  epilepsy  a  curable  disease. 

I  can  find  no  statistics  in  this  country  comparable 
with  Turner's;  one  reason  being  the  lack  of  age  of 
special  institutes  for  this  class ;  another,  the  difference 
in  the  types  of  cases  studied  in  city  dispensaries,  such 
as  the  National  Hospital  for  the  Paralyzed  and  Epi-, 
leptic,  London,  as  compared  with  those  sent  to  in- 
stitutions. 

Out  of  1070  patients  first  admitted  to  the  Craig 
Colony,  15  only — less  than  i£  per  cent. — had  suffered 
from  epilepsy  less  than  a  year;  197,  from  one  to  five 
years;    267,  from  five  to  ten  years;    405,  from  ten  to 


294  PROGNOSIS. 

twenty  years;  156,  from  twenty  to  forty  years; 
while  30  had  had  the  disease  forty  years  or  more. 

Notwithstanding  the  chronicity  of  the  affection  in 
these  cases,  the  results  following  treatment  in  many 
of  them  were  such  that  I  have  no  hesitancy  in  stating 
that  epilepsy  is  not  infrequently  a  curable  disease 
irrespective  of  its  duration,  the  rule  being  that  recent 
cases  are  twice  as  likely  to  respond  to  treatment  as 
chronic  ones. 

In  substantiation  of  this,  in  part,  the  following 
cases  of  recovery  are  briefly  cited: 

Case  I. — A  boy,  aged  ten  years  at  onset  of  epilepsy, 
which  followed  an  attack  of  scarlatinal  nephritis. 
Attacks  were  mostly  petit  mal,  occasionally  grand  mat. 
For  sixteen  years  they  averaged  from  115  to  125  a 
month.  The  patient's  mental  condition  on  admission 
was  not  robust,  due  largely  to  the  effects  of  the  exces- 
sive use  of  the  bromids.  He  was  under  treatment 
for  two  years  and  two  months.  During  the  first  month 
he  had  115  attacks,  during  the  second  98,  during  the 
third  13,  during  the  fourth,  none,  and  during  the  fifth, 
one;  after  which  they  ceased  entirely.  Seven  years 
later  they  had  not  recurred.  All  told,  he  had  50,000 
to  60,000  attacks.  The  cure  in  this  case  seems  com- 
plete. 

Case  II. — A  girl,  aged  six  years  at  onset  of  epilepsy, 
which  followed  emotional  shock  due  to  fright.  Attacks 
at  first  were  all  grand  mal,  later  changing  to  petit  mal, 
and  occurring  at  the  rate  of  one  a  day.  The  disease 
had  existed  twenty-seven  years  when  the  patient 
entered  the  Colony.  She  was  under  treatment  two 
years  and  a  half,  and  five  years  after  her  discharge 
was  well  in  every  respect. 

Case  III. — A  boy,  aged  fourteen  years  at  onset  of 
epilepsy,  which  was  ascribed  to  heredity  and  mas- 
turbation. The  disease  had  existed  two  years  when 
the  patient  came  ■  under  treatment.  All  were  grand 
mal  and  occurred  at  first  six  months  apart,  later 
changing  to  one  a  month.  Mental  condition  was  un- 
impaired; a  slight  vicious  tendency  was  noted  at 
times.     He  was  kept  under  treatment  for  two  years 


RECOVERY    UNDER    TREATMENT.  295 

and  four  months,  and  five  years  later  had  experienced 
no  further  trouble. 

Case  IV. — A  man,  aged  fifty-seven  years  at  onset  of 
epilepsy.  Assigned  cause,  senile  changes;  probable 
cause,  dissolute  livjng.  All  attacks  were  grand  trial, 
occurring  at  first  once  a  month,  then  once  in  three 
months.  There  was  no  mental  impairment.  He  was 
under  treatment  for  two  years  and  four  months. 
Five  years  later  he  was  perfectly  well. 

Case  V. — A  boy,  aged  sixteen  years  at  onset  of  epi- 
lepsy, which  was  ascribed  to  congenital  defect  and 
dissolute  habits.  All  attacks  were  grand  mal,  occur- 
ring at  first  weekly,  then  once  a  month.  Mental 
condition  was  not  impaired.  He  was  under  treat- 
ment two  years.  Five  years  and  two  months  later  the 
attacks  had  not  recurred. 

Case  VI. — A  girl,  aged  nineteen  years  at  onset  of 
epilepsy,  which  was  due  to  emotional  shock  from 
fright.  The  patient  was  of  a  sensitive,  nervous 
organization,  easily  influenced.  All  attacks  were 
grand  mal.  They  occurred  on  an  average  four  times 
a  year.  The  disease  had  existed  a  year  before  admis- 
sion. She  was  under  treatment  one  year  and  nine 
months,  and  five  years  later  the  attacks  had  not 
recurred. 

Case  VII. — A  boy,  aged  eleven  years  at  onset  of 
epilepsy,  which  was  due  to  heredity  and  masturbation. 
All  attacks  were  grand  mal,  occurring  at  first  weekly, 
later  twice  a  week.  Mental  condition  was  unimpaired. 
Duration  of  epilepsy  on  admission,  four  years;  dura- 
tion of  treatment,  one  year  and  five  months.  Four 
years  later  the  attacks  had  not  recurred. 

Case  VIII. — A  young  man,  aged  twenty  years  at 
onset  of  epilepsy,  which  was  due  to  alcohol.  All 
attacks  were  grand  mal,  severe  in  character,  and 
occurred  two  weeks  apart.  Duration  of  epilepsy  on 
admission,  ten  years;  duration  of  treatment,  three 
years.  A  year  and  six  months  later  the  attacks  had 
not  recurred. 

Case  IX. — A  girl,  aged  seven  years  at  onset  of  epi- 
lepsy, which  was  ascribed  to  congenital  defect  and 
irritation  incident  to  the  second  dentition.  Only  one 
attack  at  that  time,  the  second  occurring  three  years 


296  PROGNOSIS. 

later,  after  which  they  appeared  every  month.  All 
attacks  were  grand  mal.  Duration  of  the  disease  on 
admission,  seven  years;  duration  of  treatment,  two 
years.  Mental  condition  was  not  impaired.  Three 
years  later  the  attacks  had  not  recurred. 

Case  X. — A  boy,  aged  eight  years  at  onset  of  epilepsy, 
which  was  ascribed  to  congenital  defect  and  "over- 
excitement."  Attacks  were  both  grand  mal  and  petit 
mal,  the  latter  predominating.  They  occurred  at  the 
rate  of  one  a  week.  Mental  condition,  imbecile. 
Duration  of  epilepsy  on  admission,  twelve  years. 
Three  years  later  attacks  had  not  recurred.  Mental 
condition  was  improved. 

Case  XL — A  boy,  aged  seven  years  at  onset  of  epi- 
lepsy, which  was  ascribed  to  heredity  and  the  "  stress' ' 
attending  the  second  dentition  period.  All  attacks 
were  grand  mal,  occurring  at  first  once  a  week;  later 
from  three  to  four  days  apart.  Mental  condition  was 
not  impaired.  Duration  of  epilepsy  on  admission, 
seven  years;  duration  of  treatment,  three  years. 
One  year  and  three  months  later  attacks  had  not 
recurred. 

Case  XII. — A  girl,  aged  eight  years  at  onset  of 
epilepsy,  which  was  ascribed  to  indigestion.  Mother 
suffered  from  disease  of  the  spine;  father  had  menin- 
gitis at  the  age  of  twenty- two.  Both  parents  were 
nervous  and  subject  to  headaches.  All  attacks  were 
grand  mal,  occurring  at  first  once  a  year;  during  the 
three  years  prior  to  admission,  from  three  to  five  times 
a  year.  No  mental  impairment.  Duration  of  epi- 
lepsy on  admission,  seven  years;  duration  of  treat- 
ment, three  years  and  a  half.  Two  years  later  attacks 
had  not  recurred. 

Case  XIII. — A  young  man,  aged  eighteen  years  at 
onset  of  epilepsy,  which  was  ascribed  to  sexual  excesses 
and  masturbation.  All  attacks  were  petit  mal,  occur- 
ring at  first  from  six  to  twelve  months  apart;  later 
several  times  a  day.  Mental  condition  was  un- 
impaired. Duration  of  disease  on  admission,  two 
years;  duration  of  treatment,  two  years.  Sixteen 
months  later  the  disease  had  not  recurred. 

Case  XIV. — A  boy,  aged  fifteen  years  at  onset  of 
epilepsy,  which  followed  an  attack  of  typhoid  fever. 


RECOVERY  UNDER  TREATMENT.         297 

Attacks  divided  between  grand  mal  and  petit  mal, 
and  occurring  from  four  to  five  months  apart.  Mental 
condition  was  not  impaired.  Duration  of  epilepsy 
on  admission,  five  years;  duration  of  treatment, 
two  years.  Eighteen  months  later  the  attacks  had 
not  recurred. 

Case  XV. — A  boy,  aged  five  years  at  onset  of  epi- 
lepsy, which  was  ascribed  to  congenital  defect.  AH 
attacks  were  grand  mal,  occurring  once  a  month. 
Mental  condition  was  unimpaired.  Duration  of  epi- 
lepsy on  admission,  two  years ;  duration  of  treatment, 
twelve  months.  The  patient  was  sent  home  on  trial. 
Four  years  later  the  attacks  had  not  recurred. 

Case  XVI. — A  girl,  aged  fifteen  years  at  onset  of 
epilepsy,  which  was  ascribed  to  heredity  and  the  stress 
of  the  first  menstrual  epoch;  she  was  an  imbecile, 
with  deficient  memory,  and  all  mental  processes  slow 
and  imperfect.  All  attacks  "were  grand  mal,  occurring 
on  an  average  once  a  month.  Duration  of  epilepsy 
on  admission,  two  years;  duration  of  treatment,  two 
years  and  a  half.  Five  years  later  the  attacks  had 
not  recurred. 

In  addition  to  the  above  sixteen  patients  regarded 
as  cured,  there  were  under  my  observation  on  October 
1,  1903,  fifteen  others  who  had  gone  eighteen  months 
or  longer  without  an  attack.  All  these  bid  fair  to 
make  a  complete  recovery. 

Many  are  incurable  on  admission.  If  we  accept 
the  mental  condition  as  a  guide  in  prognosis,  fully 
half  of  all  admitted  to  institutions  like  the  Craig 
Colony  must  be  considered  incurable.  Fully  50  per 
cent,  show  mental  impairment,  being  either  demented, 
feeble-minded,  imbecile,  idiotic,  or  insane. 

Taking  the  1286  cases  admitted  up  to  October, 
1902,  and  deducting  half  as  palpably  incurable,  we 
have  643  more  or  less  chronic  cases  left.  Of  this 
number  sixteen  patients  are  reported  as  cured,  and 
fifteen  others  bid  fair  to  attain  the  same  end,  having 
gone  eighteen  months  or  longer  without  an  attack. 
Add  these  and  we  have  thirty-one — practically  5  per 
cent,  of  the  total  number  of  possibly  curable  cases. 


298  PROGNOSIS. 

I  have  previously  stated  that  less  than  i£  per  cent, 
of  the  total  number  of  patients  admitted  to  the  Colony 
had  had  epilepsy  less  than  a  year  when  they  came 
under  treatment.  It  seems  fair,  on  the  whole,  to 
say  that  even  with  an  almost  entirely  chronic  class 
we  may  expect  a  cure  in  about  5  per  cent.  If  all 
could  come  under  treatment  early  enough,  this  per- 
centage could  undoubtedly  be  doubled  or  trebled. 

The  Influence  of  Sex. — Sex  apparently  plays  little 
part  in  the  prognosis  of  epilepsy.  In  Turner's  366 
cases,  the  number  of  arrests  in  the  men  was  twenty- 
six,  in  the  women  twenty.  At  the  same  time,  the 
number  of  confirmed  cases  was  greater  in  the  men  than 
in  the  women. 

In  the  sixteen  Colony  cases  reported  as  cured, 
eleven  were  men ;  while  in  the  fifteen  mentioned  as 
having  no  attacks  for  eighteen  months,  twelve  were 
men.  This  difference  in  ratio  is  explained  in  part 
by  the  greater  number  of  men  under  treatment.  If 
there  is  a  difference  in  the  curability  of  the  two  sexes, 
I  incline  to  think  that  it  favors  the  male  side.  Atten- 
tion was  called  in  Chapter  III  to  the  fact  that  the 
disease  is  more  common  among  men  than  among 
women,  in  the  ratio  of  twenty  of  the  former  to  sixteen 
of  the  latter. 

The  Influence  of  Age. — The  average  age  at  the  onset 
of  the  disease  in  the  sixteen  cases  of  recovery  was 
fifteen  years.  Epilepsy  beginning  under  ten  years 
is  least  favorable  as  regards  cure  or  improvement, 
while  cases  in  which  the  arrest  occurs  between  the 
fifteenth  and  twentieth  year  are  most  favorable. 
From  the  twentieth  to  the  thirtieth  or  thirty-fifth 
year  there  is   a  steady  decline  in  the  curable  cases.* 

*  "Those  cases  of  epilepsy  that  come  on  before  puberty  may  undergo 
a  change,  but  those  which  come  on  after  twenty-five  years  of  age  for  the 
most  part  terminate  in  death."  Hippocrates'  "Aphorisms,"  Section  5, 
Vol.  11;  "Sydenham  Society's  Translation,"  Vol.  II,  p.  738. 


RECOVERY    UNDER    TREATMENT. 


299 


After  the  thirty-fifth  year,  the  number  of  intractable 
cases  diminishes  noticeably.  This  is  probably  due 
to  not  infrequent  unessential  forms  of  the  disease  after 
this  age.  "Senile  epilepsy  is  essentially  a  tractable 
disorder"   (Turner).     In  this  statement  I  agree. 

The  following  table  shows  the  relation  of  age,  at 
the  onset  of  the  epilepsy  and  its  duration,  to  the  mental 
condition  in  1334  cases:  806  males,  528  females. 


Mental  State. 

Number 
of  Cases. 

Male. 

Female. 

Average  Age 
at  Onset. 

Average  Dura- 
tion of  Epilepsy. 

Good 

241 

402 

488 

90 

97 
16 

142 

251 

282 

62 

58 

11 

99 

151 

206 

28 

39 

5 

14. 1  years. 
13 

9-7       " 
26.6       " 

5-3       " 
3-76     " 

9.8  years. 
11. 12     " 

13.1  " 

15.2  " 
n-57     " 

9-35     " 

Fair 

Feeble 

Demented 

Imbeciles 

Idiots 

Total 

1334 

806 

528 

12.4 

11.9 

By  it  we  see  that  the  average  age  at  the  onset  of 
the  epilepsy  in  those  whose  mental  state  was  good, 
was  14. 1  years.  It  also  shows  that  (with  the  exception 
of  the  idiotic  class)  the  disease  had  existed  in  the  class 
indicated  as  "good"  for  a  less  time  than  in  any  other, 
the  average  being  9.8  years.  It  is  an  interesting  fact 
to  note  that  those  having  epileptic  dementia  acquired 
epilepsy  at  the  average  age  of  26.6  years,  nearly  double 
the  age  found  in  any  other  class. 

The  percentage  of  male  and  female  epileptics  in  each 
mental  class  is  as  follows : 


Fair 

Feeble 
Demented 
Imbeciles  . 
Idiots  . . . . 


ale,  17.6  per  cent. 

Female, 

16.8  per  cent 

"      3i-i 

" 

28.5 

"      34-9 

" 

39- 

"        7.6         " 

" 

5-2 

7.1 

" 

7-4 

1.3 

" 

•9 

This  indicates  a  greater  tendency  for  male  epileptics 
to  retain  bettermental  states  under  ' '  good,"  ' '  fair,"  and 
"feeble"  than  female  epileptics,  while  a  slightly  greater 


3°° 


PROGNOSIS. 


number  of  male  epileptics  reach  dementia,  imbecility, 
and  idiocy.  This  confirms  the  seemingly  greater  num- 
ber of  cures  among  males  than  among  females,  for  the 
mental  condition  has  much  to  do  with  it. 

An  additional  fact  of  great  interest  in  this  connection 
is  found  in  a  study  of  the  proportion  of  cases  having 
a  neuropathic  heredity  in  each  of  the  mental  states 
given. 


Good. 

Fair. 

Feeble. 

Demented. 

Imbeciles. 

Idiots. 

Per  cent. 

Per  cent. 

Per  cent. 

Per  cent. 

Per  cent. 

Per  cent 

33$ 

37-5 

27.4 

21.8 

24.6 

33i 

This  shows  that  the  most  amenable  cases  to  treat- 
ment— those  included  under  good  and  fair  mental 
states — most  often  have  a  neuropathic  heredity,  which 
is  confirmatory  of  the  statements  of  Gowers,  Turner, 
and  others. 

The  Influence  of  Frequency  of  Attacks. — The  fol- 
lowing table  shows  the  relation  of  mental  condition 
at  the  time  of  admission  to  frequency  of  attacks. 


Interval  between  Attacks. 

Good. 

Fair. 

Feeble. 

De- 
mented. 

Imbe- 
cile. 

Idiot. 

Less  than  three  weeks 

Three  to  four  weeks 

Over  one  month 

Per 
cent. 

58.8 
22.8 
18.3 

Per 
cent. 

68.6 

24.4 
11 

Per 
cent. 

76.6 

13-8 

9-3 

Per 
cent. 

77-5 

15-5 

7 

Per 
cent. 

89.2 
8 
2.6 

Per 
cent. 

72 

i6§ 
11. 1 

It  is  clear  that  the  more  often  the  attacks  occur  the 
less  favorable  is  the  mental  condition.  Beginning 
with  a  percentage  of  58.8  per  cent,  of  those  marked 
good  arid  in  whom  attacks  occurred  less  than  three 
weeks  apart,  the  number  runs  steadily  up  as  the 
mental  state  falls,  until  we  find  89.2  per  cent,  of  the 
imbeciles  having  seizures  less  than  three  weeks  apart. 
It  is  also  noted  that  those  marked  good  have  the 
highest  percentage  (18.3  per  cent.)  of  attacks  which 
appear  over  a  month  apart. 

The    character    and    time    of    seizures    apparently 


RECOVERY    UNDER    TREATMENT.  30I 

modify  the  prognosis  to  some  extent.  It  is  generally 
known  that  grand  mal  seizures  are  more  amenable  to 
treatment  than  petit  mal  or  psychic  attacks. 

It  is  also  well  known  that,  as  a  rule,  major  attacks 
do  not  tend  so  frequently  to  impair  or  destroy  the 
mind  as  do  the  lesser  attacks.  Next  to  grand  mal  in 
this  respect  come  grand  mal  and  petit  mal  combined, 
while  psychic  attacks  are  the  least  tractable  of  all. 
There  are  some  exceptions  to  this. 

For  six  years  a  girl,  who  was  eight  years  of  age  when 
the  attacks  began,  averaged  from  forty  to  sixty  psychic 
seizures  daily,  when  they  began  to  decrease,  appearing 
four  or  five  times  only  in  twenty-four  hours,  again 
disappearing  completely  for  days  at  a  time.  Notwith- 
standing all  these,  she  developed  naturally,  mentally 
and  physically,  grew  strong  and  robust,  and  at  the 
age  of  fourteen  showed  every  prospect  of  becoming  rid 
of  the  seizures  entirely. 

In  other  cases  in  which  the  attacks  are  almost 
identical  with  this,  mental  enfeeblement  begins  to 
show  in  a  year  or  so,  and  in  three  or  four  years  the 
patient  is  demented. 

Why  there  is  this  radical  difference  in  outcome 
between  cases  almost  symptomatically  identical,  is 
not  known.  The  personal  equation  represented  in 
individual  stamina,  together  with  the  cause,  may 
explain  it  in  part. 

Attacks  that  occur  during  the  day,  including  those 
of  the  early  morning  (the  post-dormitium  period), 'give 
a  larger  percentage  of  cures  than  those  occurring  only 
during  the  night.  I  would  explain  this  on  the  ground 
that  nocturnal  attacks,  commonest,  as  we  have  seen, 
about  three  o'clock  in  the  morning,  overtake  the  in- 
dividual when  vitality  is  at  its  lowest  ebb.  The  very 
robust  are  generally  not  so  apt  to  have  seizures  at 
night. 

The  Influence  of  the  Catamenia.— The  establishment 


302  PROGNOSIS. 

of  the  menstrual  epoch  appears  to  exert  but  little 
influence  on  the  disease,  beyond  increasing  in  some 
cases  the  number  of  attacks  at  that  time.  It  has 
been  quite  generally  held  that  the  onset  of  the  men- 
strual function  exerts  a  favorable  influence  on  the 
disease,  but  there  is  nothing  within  my  knowledge 
to  justify  such  a  belief.  The  opposite  is  more  often 
true.  The  table  below  shows  how  this  period  aug- 
ments the  attacks. 

FREQUENCY  OF  ATTACKS  IN   1374  CASES. 

Number  having        Approximate 
Attacks.  Per  Cent. 

Attacks  weekly  or  more  often 775  57 

every    two  weeks 173  13 

"        three  weeks 61  4 

"            "       four  weeks 244  18 

"        eight  weeks 42  3 

"        twelve  weeks 49  4 

"        six  months  or  over 30  2 

Here  the  four-weeks'  period  is  greater  than  any 
other  save  the  first,  in  which  the  attacks  occurred 
weekly  or  more  often,  and  is  due  to  the  influence  of 
the  catamenia.  It  is  not  uncommon  for  the  menstrual 
period  to  be  irregular  in  its  manifestations  if  epilepsy 
develops  during  puberty. 

The  Influence  of  Marriage. — The  marriage  of  epilep- 
tics is  sometimes  urged  for  its  supposed  favorable 
influence  on  the  disease,  but  so  far  as  my  observation 
goes,  there  is  nothing  to  warrant  commendation  of 
the  practice, — marriage  having  no  beneficial  effect  on 
the  disease  in  any  of  numerous  similar  cases  that  I 
have  personal  knowledge  of.  In  some  of  them  it 
seemed  to  lessen  the  frequency  and  severity  of  the 
attacks  for  a  short  time. 

Irrespective  of  this,  marriage  confers  a  license  for 
the  creation  of  a  diseased  progeny  generally  lower  in 
mental,  moral,  and  physical  stamina  than  their  ante- 


RECOVERY  UNDER  TREATMENT.         303 

cedents.  This  fact  alone  should  be  sufficient  to  deny 
the  epileptic  the  right  of  marriage  in  fully  ninety-five 
out  of  every  hundred  cases  in  which  it  is  sought. 

The  value  of  the  aura  in  prognosis  in  certain  cases 
is  considerable.  It  is  of  great  value  in  cases  in  which 
motor  manifestations  are  most  pronounced,  and,  as  a 
general  rule,  the  greater  the  length  of  time  between 
the  appearance  of  the  aura  and  the  fit,  the  more  readily 
will  the  case  yield  to  treatment. 

In  many  cases  of  reflex  epilepsy  the  relationship 
between  discoverable  cause  and  effect  is  often  unmis- 
takable. We  need  only  refer  to  the  list  of  causes 
active  in  such  cases  to  see  that  this  is  so.  These  in- 
clude gastro-intestinal  irritations,  urethral  stricture, 
helminthes  of  various  kinds,  nasal  growths,  old  cica- 
trices, recent  trauma  to  the  head,  etc. 

A  woman  of  middle  age  (to  whom  reference  has 
before  been  made)  never  menstruated.  Shortly  after 
the  beginning  of  the  period  of  menstrual  life  she 
began  to  have  convulsions  described  as  epileptic,  the 
prodromal  periods  of  which  consisted  in  headache, 
marked  irritability  of  temper,  and  malaise,  all  of  which 
steadily  grew  in  intensity  for  some  days  before  the 
catamenia  should  appear. 

She  was  found  to  have  an  impervious  uterus,  the 
removal  of  which,  with  both  ovaries,  checked  the 
attacks  at  once,  which  four  years  later  had  not  recurred. 

The  aura  in  this  case  measured  the  degree  of  poison- 
ing due  to  the  systemic  absorption  of  the  menstrual 
discharge. 

Spontaneous  Recovery. — Instances  of  this  kind  have 
been  reported,  but  they  are  far  too  infrequent  and 
too  uncertain  on  which  to  base  any  hope  in  a  given 
case. 

The  tendency  of  the  disease  is  always  toward  self- 
perpetuation, — a  fact  attested  to  by  the  common 
recognition   of   habit   epilepsy   in   which   the   disease 


304  PROGNOSIS. 

appears  after  the  original  cause  has  been  removed,  as 
well  as  by  the  teachings  of  the  most  experienced 
neurologists. 

Not  infrequently  convulsive  attacks  in  infancy, 
which  continue  to  occur  after  the  removal  of  the 
exciting  cause,  disappear  spontaneously.  Later  on, 
on  the  other  hand,  attacks  in  childhood  may  suddenly 
cease  to  recur  at  puberty.  This  is  one  of  the  most 
remarkable  features  of  the  disease.  In  the  chapter  on 
the  Drug  Treatment  reference  is  made  to  the  influence 
of  intercurrent  affections  on  the  course  of  the  disease. 

The  Danger  to  Life. — The  danger  to  life  from  epi- 
lepsy, according  to  Gowers,  is  not  great;  while  Fere 
says  epilepsy  is  always  a  serious  affection.  These  two 
statements  are  in  a  measure  harmonious.  If  we  hold 
that  a  disease  which  destroys  life  suddenly  and  without 
warning  through  a  single,  brief  attack,  unaided  by  an 
accident  to  the  patient  at  the  moment,  such  as  .suffoca- 
tion, or  fracture  of  the  skull  from  falling,  and  does  so 
in  from  3  to  4  per  cent,  of  all  who  suffer  from  it, 
we  may  consider  its  danger  to  life  in  the  same  light 
that  Gowers  does,  for  this  rate  of  mortality  for  a 
single  disease  is  not  excessively  high. 

If,  on  the  other  hand,  we  feel  that  epilepsy  in  any 
form  may  suddenly  produce  death  in  any  case,  and 
that  its  presence  leads  indirectly  to  a  fatal  termination 
through  its  tendency  to  the  establishment  of  other 
grave  disorders,  we  may  agree  better  with  Fere,  who 
says  it  is  a  serious  affection. 

Epilepsy  should  never  be  counted  among  the  dis- 
eases that  do  not  threaten  life.  The  most  robust  of 
its  victims  may  succumb  through  a  single  attack. 
Several  cases  which  prove  this  have  come  under  my 
notice. 

It  is  not  safe  to  argue  that  the  mildness  of  the  attacks 
always  indicates  comparative  freedom  from  danger, 
though,  as  a  rule,  accidents  in  such  cases  are  rare. 


RECOVERY  UNDER  TREATMENT.         305 

A  verv  common  cause  of  death  in  epilepsy  is  pul- 
monary tuberculosis,  this  being  the  cause  in  24  per 
cent,  of  150  deaths  at  Sonyea.  This  would  seem  to 
show  that  epileptics  are  more  prone  to  diseases  of  the 
lungs  than  those  not  epileptic.  On  comparing  this 
ratio — one  death  in  four  in  epilepsy  due  to  tubercu- 
losis— with  the  ratio  of  deaths  from  all  causes  in  New 
York  State,  during  the  years  1900  and  1901,  we  find 
that  the  percentage  of  deaths  from  tuberculosis  was 
about  9^.  These  figures  are  not  presented  as  con- 
clusive, but  merely  as  showing  a  tendency  seemingly 
worthy  of  further  study. 

Next  to  tuberculosis  in  point  of  cause,  stands  status 
epilepticus.  The  onset  of  this  is  a  danger  signal 
likely  to  be  displayed  in  every  epileptic's  life.  No 
form  of  the  disease  may  escape  it.  It  may  follow 
hundreds  of  violent  seizures,  or  may  follow  two  or 
three  exceedingly  mild  ones,  constituting  in  the  latter 
cases  masked  status,  a  condition  fully  as  fatal  as  status 
epilepticus  of  the  classical  type. 

Serial  attacks  seldom  have  a  fatal  termination, 
though  they  may  pass  into  status  and  produce  death 
in  that  way. 

Organic  diseases  of  the  heart  also  seem  to  play  a 
conspicuous  part  in  causing  death  in  epilepsy.  It  was 
found  in  some  form  in  nearly  10  per  cent,  of  the 
Colony  cases,  though  it  was  not  the  actual  cause  of 
death  in  this  number.  When  death  occurs  during 
an  attack  in  an  individual  who  has  organic  heart  dis- 
ease, it  may  be  difficult  to  know  how  much  influence 
to  attribute  to  the  epilepsy  and  how  much  to  the 
heart  disease,  though,  as  a  rule,  symptoms  of  asphyxi- 
ation usually  make  epilepsy  as  a  cause  comparatively 
clear. 

The  manner  in  which  accidents  are  received  by 
epileptics  varies  widely,  including  falling  downstairs, 
from  windows,  into  water,  being  struck  by  railway 


306  PROGNOSIS. 

trains,  choking  while  eating,  falling  in  dangerous  posi- 
tions, and  others  too  numerous  to  mention. 

A  boy  was  standing  with  his  back  to  the  top  of  a 
short  flight  of  steps  that  led  to  a  cellar  with  a  cement 
floor.  A  convulsion  seized  him,  threw  him  down  and 
over  the  stairs,  so  that  his  head  struck  posteriorly  on 
the  stone  floor,  death  resulting  in  half  an  hour  from 
a  fracture  of  the  skull,  which,  beginning  at  the  base, 
almost  completely  encircled  it  in  a  rising  line  as  it 
extended  forward  on  either  side. 

Another  male  epileptic  fell  downstairs  during  a 
seizure  and  broke  his  neck. 

A  man  entered  a  small  toilet-room,  closed  the  door, 
had  a  seizure  and  fell  in  such  a  way  as  to  brace  his 
feet  against  one  wall  and  his  head  against  the  door, 
the  head  being  wedged  forward  and  crowding  the  chin 
against  the  chest  and  right  shoulder.  When  removed 
he  was  limp  and  unconscious  and  died  shortly  after 
as  the  result  of  a  fracture  of  the  sixth  cervical  vertebra, 
as  shown  by  the  autopsy. 

An  adult  male  epileptic  sat  on  a  chair  near  an  iron 
bedstead  that  had  a  right  angle  rail  down  the  side. 
He  had  a  convulsion  and  fell  forward  in  such  a  manner 
as  to  strike  with  his  throat  squarely  across  the  sharp 
edge  of  the  iron  rail.  When  found  later  he  was  dead, 
his  entire  weight  having  been  supported  by  his  throat 
against  the  rail,  his  legs  being  out  almost  at  full 
length. 

I  have  already  mentioned  the  woman  who  died  in 
an  upright  position.  These  cases  are  cited  to  show 
some  of  the  more  unusual  causes  and  manner  in  which 
epilepsv  destroys  life.  We  need  not  be  surprised  to 
find  an  epileptic  dead  in  any  posture,  or  under  any 
circumstances. 

"The  question  of  sudden  death,"  says  Brouardel,* 
"in  the  course  of  an  attack  of  epilepsy  is  of  great 

*  "Death  and  Sudden  Death,"   1902,  p.   185. 


RECOVERY  UNDER  TREATMENT.         307 

interest.  In  such  cases  death  is  due  either  to  rupture 
of  the  heart,  or  to  passage  of  food  from  the  mouth 
or  stomach  into  the  trachea  or  bronchi,  or  to  asphyxia- 
tion resulting  from  the  position  occupied  by  the 
patient  during  the  fit,  such  as  may  cause  the  mouth 
to  be  pressed  into  the  pillow. 

"  But  besides  these,  there  is  another  mode  of  death 
which,  in  all  probability,  sometimes  occurs  during  a 
fit  of  epilepsy,  namely,  sudden  paralysis  of  the  respira- 
tory center.  Its  occurrence  was  firmly  believed  in 
and  taught  by  the  late  Dr.  Hilton  Fagge,  and  it  is, 
perhaps,  the  best  explanation  that  can  be  given  of 
the  death  of  those  chronic  epileptics  who  are  occasion- 
ally found  to  have  died  in  their  sleep  without  any 
evidence  of  their  having  been  asphyxiated." 

In  addition  to  deaths  occurring  during  sleep,  as 
described  by  Brouardel,  from  respiratory  failure,  I  am 
firmly  of  the  opinion  that  they  may  occur  in  the 
waking  state  as  the  result  of  the  same  cause,  for  such 
cases  have  come  under  my  observation,  which  could 
not  be  explained  in  any  other  way. 

Out  of  every  one  hundred  epileptics  who  die,  about 
four  do  so  as  the  result  of  a  single  seizure;  about 
twenty-four  as  the  result  of  status  epilepticus;  about 
twenty-four  as  the  result  of  some  disease  of  the  lungs, 
chiefly  tuberculosis;  about  twelve  as  the  result  of 
some  accident,  including  suffocation  in  bed;  about  ten 
as  the  result  of  some  organic  disease  of  the  heart ;  and 
about  twenty-six  from  all  other  causes.* 

The  Influence  of  Epilepsy  on  Longevity. — Epilepsy 
tends  to  shorten  life.  It  does  this  in  two  ways :  first, 
by  its  effects  alone  in  many  cases,  as  we  have  already 
seen;  and,  secondly,  through  its  establishment  so 
early  in  life  that  the  majority  of  those  who  die  through 
its  effects  do  so  before  middle  age  is  reached.     In  150 

*  Spratling,  "The  Causes  and  Manner  of  Death  in  Epilepsy,"  "Medical 
News,"  January  28,  1902. 


308  PROGNOSIS. 

cases  in  which  death  occurred,  the  average  age  at 
death  was  29.46  years. 

While  this  is  not  a  sufficient  number  on  which  to 
base  conclusive  opinions,  it  is  large  enough  to  show 
that  epilepsy  tends  to  shorten  life  very  materially. 

The  average  age  at  death  in  epilepsy  is  noticeably 
lower  than  that  of  insanity.  In  a  State  hospital  for 
the  insane  *  in  which  134  deaths  occurred  in  1902,  the 
average  age  at  death  was  fifty-four  years.  In  a  total 
of  20,086  deaths  in  the  New  York  State  Hospitals  for 
the  Insane  during  fourteen  years,  1330  only  were  under 
thirty  years  of  age,  the  average  age  at  death  being 
nearer  fifty  years  than  thirty  years.  The  average  age 
at  the  onset  of  insanity  is  between  thirty  and  forty 
years,  while  in  epilepsy  it  is  between  ten  and  twenty 
years. 

*  New  Jersey  State  Hospital  at  Morris  Plains:  "Report  for  1902." 


CHAPTER  XII. 

PATHOLOGY  OF  EPILEPSY. 

By  Thomas  p.  prout,  m.d.,  and  L.  Pierce  Clark,  M.d. 

Introduction.      Gross  Pathology.      Microscopic  Pathology.      Pathogenesis. 
Clinical  Interpretation  of  the  Present  Pathologic  Status  of  Epilepsy. 

INTRODUCTION. 

It  is  not  necessary  to  review  the  history  of  the 
pathology  of  epilepsy  here.  Most  of  the  theories  of 
the  past  are  now  purely  of  historic  interest  and  the 
scope  of  this  work  will  not  admit  of  their  general 
revival.  The  theories  which  have  formed  the  real 
stepping-stones  in  the  progress  of  our  knowledge  will 
not,  however,  be  omitted. 

The  work  of  the  past  has  been  progressive  at  every 
stage;  but  that  of  the  last  few  years  has  seemed  to 
advance  more  rapidly  than  that  of  earlier  periods, 
and  we  shall  have  occasion  to  mention  some  of  the 
men  whose  work  has  played  an  important  role  in  this 
progress. 

The  experimental  pathologist  and  physiologist  de- 
serve great  credit  for  much  of  our  present  knowledge. 
In  judging  of  their  work,  however,  we  must  not  forget 
its  limitations.  Convulsions  experimentally  produced 
on  the  lower  animals  are  not  epilepsy,  and  are  unac- 
companied by  many  of  its  cardinal  symptoms.  Such 
phenomena  remain  simple  convulsive  phenomena 
from  start  to  finish,  and  can  no  more  be  regarded  as 
true  or  idiopathic  epilepsy  than  many  other  cerebral 
disorders  accompanied  by  convulsions.     These  facts 

309 


3IO  PATHOLOGY    OF    EPILEPSY. 

were  overlooked  by  many  of  the  earlier  investigators. 
Brown-Sequard's  classic  experiments  in  producing 
epileptiform  attacks  in  guinea-pigs  were  open  to  this 
charge.  The  nervous  organization  of  frogs  and  guinea- 
pigs  is  so  far  removed  from  that  of  man  that  an  ex- 
perimental analogy  is  hardly  to  be  considered  seri- 
ously. Such  experiments  were  useful  in  demonstra- 
ting that  fits  of  an  epileptiform  nature  follow  certain 
forms  of  irritation,  and  these  earlier  experiments,  of 
which  Westphal's  were  also  a  type,  form  the  founda- 
tion for  much  of  our  present  conception  of  epilepsy. 
The  early  belief  that  epilepsy  was  a  disease  of  medul- 
lary origin,  supported  as  it  was  by  Marshall  Hall, 
Schroeder  van  der  Kolk,  and  others,  rapidly  gained 
many  adherents  and  reached  its  climax  in  the  pro- 
mulgation of  an  epilepto-genetic  center  in  the  medulla 
by  Nothnagel.  This  theory  was  entangled  with  many 
others  which  are  now  almost  forgotten,  such  as  the 
opinion  that  epilepsy  was  due  to  a  spasm  of  the 
arterioles,  a  diseased  condition  of  the  basal  ganglia, 
sympathetic  system,  or  sclerosis  of  the  cornu  am- 
monis. 

The  discovery  of  the  electrical  irritability  of  certain 
portions  of  the  cerebral  cortex,  particularly  by  Ferrier, 
Munk,  and  Fritsch  and  Hitzig,  accompanied  and  fol- 
lowed as  it  was  by  the  important  clinical  observations 
of  Hughlings  Jackson  on  partial  epilepsy,  and  the 
work  of  a  multitude  of  other  clinical  and  experimental 
observers,  swept  aside  all  other  theories  and  placed 
the  region  of  nervous  discharge  in  epilepsy  in  the 
cerebral  cortex. 

In  the  light  of  our  present  conception,  therefore,  the 
pathology  of  epilepsy  will  be  considered  under  the 
following  heads: 

I.  Gross  Pathology. 
II.   Microscopic  Pathology. 

III.   Pathogenesis. 


GROSS    PATHOLOGY.  311 

IV.  Clinical  Interpretation  of  the  Present  Patho- 
logic Status  of  Epilepsy.* 

GROSS  PATHOLOGY. 

The  range  of  gross  anatomical  states  found  in 
epilepsy  includes  almost  every  possible  lesion  of  the 
cerebrospinal  axis,  its  membranes  and  their  bony 
covering.  The  chief  of  these  are  the  conditions  of 
atrophy  and  mal-development  following  infantile 
cerebral  palsy;  localized  hemorrhage,  thrombosis, 
embolism,  and  trauma;  localized  or  general  sclerosis, 
including  sclerosis  of  the  cornu  ammonis ;  brain  tumor, 
cyst  or  skull  deformity,  either  congenital  or  acquired. 

For  the  most  part  the  gross  lesions  occurring  in 
epilepsy  occupy  a  secondary  place  in  its  causation. 
Some  are  more  remotely  secondary  than  others;  as, 
for  example,  the  skull  changes,  the  degree  of  which 
seems  to  depend  largely  upon  the  age  of  the  patient 
and  the  duration  and  severity  of  the  epilepsy.  Other 
gross  lesions,  such  as  those  following  infantile  cerebral 
palsy  and  usually  involving  considerable  portions  of 
the  cerebral  substance  itself,  do  not  occupy  so  remotely 
a  secondary  place  in  the  pathology  of  the  disease. 
Since  epilepsy  is  now  regarded  as  a  cortical  disease, 
we  can  consider  only  those  conditions  (gross  or  micro- 
scopic) which  involve  the  cortex,  of  primary  impor- 
tance pathologically.  Therefore  the  vast  majority  of 
gross  lesions  are  but  contributory  factors  in  the  pro- 
duction of  epilepsy,  and  are  of  pathologic  importance 
only  in  proportion  to  their  tendency  to  produce  an 
unstable  nervous  organism.  The  various  signs  of 
mal-development  are  only  of  importance  as  evidence 
of  the  existence   of  an  unstable   and  especially  sus- 

*  While  we  have  endeavored  to  cover  the  whole  field  of  the  pathology 
of  epilepsy,  the  details  of  method  and  technique,  more  especially  touching 
that  portion  of  this  chapter  embodying  our  own  original  work,  will  not 
be  considered.  For  this  information  the  student  is  referred  to  the  original 
articles. 


312  PATHOLOGY    OF    EPILEPSY. - 

ceptible  nervous  system.  Such,  for  example,  are  the 
microscopic  anomalies  of  the  cerebral  cortex,  described 
by  Rancoroni  in  the  brains  of  criminals  and  epileptics, 
also  the  gross  anomalies  of  brain  development  em- 
bodied in  the  frequently  described  abnormalities  of 
configuration,  or  the  gross  physical  conditions  com- 
monly embodied  in  the  stigmata  of  degeneration. 
The  observations  of  Ohlmacher  on  the  persistent 
thymus  and  the  lymphatic  diathesis  in  epileptics 
undoubtedly  belong  among  the  latter,  although  they 
may  have  a  somewhat  different  relationship  to  the 
pathology  and  pathogenesis  of  epilepsy  than  the  com- 
monly recognized  stigmata  of  degeneration. 

Having  defined  the  position  of  gross  lesions  in 
general  in  their  relationship  to  epilepsy,  we  may  pass 
to  their  more  particular  consideration. 

Skull  and  Meninges. — One  of  the  most  constant 
conditions  found  in  epilepsy  is  a  more  or  less  decided 
alteration  in  the  texture  of  the  skull,  and  this  is  often 
accompanied  by  changes  in  the  meninges.  The  skull 
is  usually  thickened,  frequently  to  a  great  extent, 
and  more  especially  in  the  occipital  portion,  although 
a  general  thickening  of  the  calvarium  is  not  infrequent. 
In  some  instances  the  thickening  is  limited  to  certain 
small  portions  of  the  skull,  causing  these  areas  to 
present  the  appearance  of  an  exostosis  involving  the 
entire  thickness  of  the  skull  generally,  or  the  external 
or  internal  table  especially.  In  most  instances,  how- 
ever, the  thickening  is  general.  Binswanger  regards 
these  changes  as  an  osteosclerosis. 

The  density  of  the  skull  is  usually  increased  with 
the  thickening,  although  this  does  not  necessarily 
follow.  This  factor  depends  more  particularly  upon 
the  age  of  the  patient.  Some  young  epileptics  present 
a  markedly  thickened  skull  which  is  at  the  same  time 
light  and  porous.  The  density,  however,  appears  to 
be  much  increased  after  the  twenty-fifth  year,  and  to 


GROSS    PATHOLOGY.  313 

be  very  marked  after  the  fortieth  year.  The  increase 
in  density  is  accompanied  by  an  increase  in  the  weight 
of  the  skull,  the  calvarium  of  the  epileptic  being  much 
heavier  than  that  of  the  normal  individual  of  the 
same  age. 

It  is  quite  probable  that  the  skull  changes  here 
described  are  a  sequence  to  the  frequent  cranial 
traumata  in  the  fits  and  the  extensive  venous  con- 
gestion accompanying  the  convulsion.  Congestion  of 
the  skull  and  meninges  as  a  consequence  of  the  epilep- 
tic seizure  is  very  constant  and  most  marked  following 
death  from  status  epilepticus  or  from  serial  fits.  The 
degree  of  engorgement  depends  somewhat  upon  the 
age  of  the  patient  and  the  consequent  density  of  the 
skull.  In  the  younger  patients  dying  during  a  status 
period,  the  vascular  engorgement  is  often  extreme, 
while  in  those  of  middle  life  and  old  age  it  is  much 
less. 

Deformities  of  the  skull  are  very  frequent  in  epilepsy, 
especially  if  one  includes  among  them  the  more  marked 
facial  asymmetries.  Binswanger,  Bourneville  and  Sol- 
lier,  and  Fere  have  been  most  active  in  calling  attention 
to  the  frequency  of  pronounced  skull  asymmetry  in 
epilepsy.  Behrend  found  a  pronounced  flattening  of 
the  back  of  the  head  in  epileptics,  and  Miiller,  in  an 
examination  of  the  heads  of  forty-three  epileptics, 
found  but  four  that  he  considered  normal. 

There  have  undoubtedly  been  included  with  these 
cases  a  goodly  number  of  epilepsies  complicated  by 
the  infantile  cerebral  palsies,  but  nevertheless  these 
figures  and  the  consensus  of  opinion  generally  con- 
cerning the  frequency  of  skull  deformities  in  epilepsy 
is  very  striking.  Deformity  is  undoubtedly  most  fre- 
quent in  the  epilepsies  engrafted  upon  an  infantile 
cerebral  hemiplegia  and  allied  conditions.  In  these 
cases  there  is  a  more  or  less  well-marked  asymmetry 
of  the  skull,  the  deformity  being  most  pronounced  on 


314  PATHOLOGY    OF    EPILEPSY. 

the  side  of  the  lesion  (Sachs  and  Peterson).  It  some- 
times happens  that  the  base  of  the  skull  takes  part 
in  the  deformity,  as  occurred  in  a  very  marked  case 
published  by  us  (Plate  19,  Fig.  1),  but  such  deformity 
is  infrequent,  and  we  believe  occurs  only  in  those  palsy 
cases  of  extreme  degree,  and  especially  those  occurring 
in  the  early  months  of  infancy. 

These  skull  changes  are  almost  always  accompanied 
by  some  degree  of  change  in  the  meninges.  This  is 
especially  true  of  those  cases  of  long  standing,  and 
particularly  of  the  infantile  cerebral  hemiplegia  types, 
in  which  condition  the  degree  of  change  in  the  dura 
and  the  pia  as  well,  is  quite  proportioned  to  the  severity 
of  the  brain  lesion  and  depends  much  upon  its  primary 
cause.  In  these  cases  the  meningeal  lesions,  while  not 
entirely  limited  to  the  areas  of  the  brain  involved,  are 
nevertheless  much  more  severe  over  these  portions, 
the  dura  being  thickened  and  markedly  adherent  to 
the  skull  and  excessively  adherent  to  the  pia.  In 
infantile  cerebral  palsy,  and  in  many  old  epileptics, 
the  dura  is  so  markedly  adherent  to  the  skull  that 
its  separation  is  a  matter  of  difficulty  and  requires 
much  care  in  its  accomplishment;  even  then  pieces 
of  the  dura  are  often  torn  away  with  the  calvarium. 
In  a  few  cases  of  this  character  the  morbid  process 
in  the  dura  mater  has  undergone  calcareous  degen- 
eration with  the  formation  of  calcareous  deposits 
within  the  substance  of  this  membrane.  In  one  of 
our  cases  this  calcareous  formation  extended  over  the 
whole  of  one  side  of  the  brain  surface.  The  patient, 
forty-one  years  old,  had  an  old  infantile  cerebral 
palsy,  the  cerebral  lesion  being  not  very  pronounced. 

The  formation  of  a  false  hemorrhagic  membrane  on 
the  inner  surface  Of  the  dura  is  not  as  frequent  in 
epileptics  in  general  as  among  the  insane.  As  regards 
epilepsy  this  condition  seems  to  be  limited  to  old 
epileptics  who  present  more  or  less  decided  mental 


GROSS    PATHOLOGY.  315 

involvement  with  accompanying  vascular  lesions.  The 
membrane,  in  the  instances  that  we  have  seen,  has 
presented  the  same  general  characteristics  as  found 
in  the  insane;  in  fact,  they  occurred  either  in  asylum 
epileptics  or  in  epileptics  who  could  have  been  cer- 
tified for  commitment.  The  membrane  was  thin, 
being  never  over  one-sixteenth  of  an  inch  thick,  non- 
adherent to  the  dura,  and  entirely  unorganized.  The 
point  of  its  origin  could  not  be  determined.  That  a 
hemorrhagic  membrane  of  this  sort  might  be  pro- 
duced by  the  fit  seems  not  improbable  when  one 
considers  the  great  age  of  the  patients  in  which  it  has 
been  observed.  It  must  be  remembered  that  it  is 
entirely  secondary,  and  is  so  thin  that  it  could  not 
possibly  give  rise  to  intracranial  pressure. 

The  subject  of  skull  injury  deserves  a  passing  note, 
since  it  frequently  initiates  the  epileptic  process, 
especially  when  occurring  over  the  motor  cortex. 
The  role  of  injuries  of  this  sort  in  initiating  the  spasm 
is  undoubted  and  is  of  special  importance  when  pre- 
ceded by  hereditary  causes.  Usually  both  tables  of 
the  skull  are  involved  in  the  injury,  the  inner  table 
pressing  upon  the  brain  surface  and  giving  rise  to  its 
irritation.  It  occasionally  happens,  as  a  result  of 
injury,  that  the  inner  table  of  the  skull  alone  is  frac- 
tured and  depressed. 

The  pia  mater  presents  frequent  changes  in  epi- 
lepsy, but  none  which  are  constant  and  characteristic. 
Of  these  the  most  frequent  is  a  certain  amount  of 
edema  and  congestion  of  the  pia,  the  latter  being  a 
sequence  of  the  vascular  engorgement  incident  to  the 
fit.  A  certain  amount  of  edema  is  quite  common  and 
is  especially  pronounced  in  old  epileptics  and  insane 
epileptics,  and  is  often  associated  with  more  or  less 
brain  wasting  and  incidental  increase  in  the  cerebro- 
spinal fluid.  Thickening  of  the  pia  mater,  frequently 
associated  with  more  or  less  well-marked  adhesions 


o 


1 6  PATHOLOGY    OF    EPILEPSY. 


between  the  pia  and  the  brain  surface,  is  quite  common 
in  epilepsy.  This  is  most  marked  in  those  epileptics 
presenting  an  infantile  cerebral  hemiplegia,  in  which 
condition  the  lesion  is  almost  constant,  but  it  exists 
independently  of  this  condition  in  about  50  per  cent, 
of  epileptics. 

Opacity  of  the  pia  occurs  but  infrequently  in  epi- 
lepsy as  compared  with  insanity.  The  reason  for  this 
is  hard  to  explain  and  would  seem  to  refute  the  sug- 
gestion of  Be  van  Lewis  that  opacity  of  the  pia  is 
especially  frequent  in  conditions  associated  with  con- 
gestion and  chronic  hyperemia.  Further  than  this, 
if  "we  must  infer  an  inflammatory  agency"  in  the 
production  of  the  extreme  degrees  of  opacity  of  the 
pia,  we  should  certainly  be  warranted  in  assuming  the 
absence  of  such  inflammatory  agency  in  epilepsy. 
One  sees  but  seldom  the  extreme  degrees  of  pial 
opacity  in  epilepsy. 

Brain.— The  old  lesions  of  an  infantile  cerebral 
hemiplegia  are  among  the  most  frequent  found  in  the 
brains  of  epileptics.  The  percentage  of  infantile 
hemiplegias  and  diplegias  that  become  epileptic  is 
variously  stated. 

In  140  cases  Sachs  and  Peterson  found  62  (44.3 
per  cent.)  epileptic.  Included  in  this  number  were 
24  diplegics,  7  of  whom  were  epileptic  (29  per  cent.), 
and  11  paraplegics,  4  of  whom  were  epileptic  (36  per 
cent.).  Among  the  105  hemiplegics,  51  had  epilepsy 
(50  per  cent.).  Osier  found  but  35  in  120  of  his  cases 
(26  per  cent.);  Wallenberg,  66  in  160  cases,  while 
Lovett  records  26  severe  cases  in  which  but  one  was 
non-epileptic  (96  per  cent.);  and  Gowers  states  that 
two-thirds  of  all  cases  of  hemiplegic  cerebral  palsies 
in  infants  ultimately  became  epileptic.  Among  264 
cases  seen  at  the  Vanderbilt  Clinic,  87  were  epileptic 
(t,3  per  cent.).  We  are  reasonably  safe  in  stating 
that  fully  40  per  cent,  of  all  the  cerebral  hemiplegics 


GROSS    PATHOLOGY.  317 

of  infancy  ultimately  become  epileptic.  In  the  pro- 
duction of  epilepsy,  the  size  of  the  lesion  appears  of 
little  consequence  compared  with  its  location.  Epi- 
lepsy may  be  engrafted  upon  a  lesion  so  slight  as  to 
escape  notice,  except  by  the  most  careful  clinical 
examination;  on  the  other  hand,  the  lesion  may  be  so 
extreme  that  one  wonders  how  the  patient  survived  the 
original  storm.  Fig.  i ,  Plate  19,  presents  a  lesion  of  this 
type  in  which  the  whole  left  cerebral  hemisphere  was 
involved.  The  less  severe  lesions  may  involve  almost 
any  portion  of.  the  cerebral  substance,  although  there 
is  often  a  distinct  tendency  to  the  involvement  of  the 
central  convolutions  in  both  hemiplegics  and  diplegics. 
This  has  been  regarded  by  some  authorities  (Freud) 
as  evidence  of  the  vascular  origin  of  the  disease.  Con- 
cerning the  exact  nature  of  the  original  lesion  in  this 
condition,  there  is  no  general  agreement.  We  are 
probably  dealing  with  a  set  of  conditions  the  result 
of  various  lesions,  which,  if  we  knew  the  original 
excitant,  would  appear  quite  simple.  Freud,  Delettre, 
Charcot,  Haubner,  and  others  have  reported  cases 
undoubtedly  the  result  of  embolism.  Abercrombie 
reports  a  case  presenting  widespread  vascular  disease 
and  thrombosis  of  the  superior  longitudinal  sinus, 
and  Gowers  suggests  thrombosis  of  the  cortical  veins 
as  the  underlying  cause.  According  to  Collier,  recent 
cases  show  no  signs  of  thrombosis.  Freud  thinks 
all  the  infectious  cases  are  embolic  and  that  the  hemi- 
plegic  cases  are  thus  best  explained. 

Strumpell's  theory  of  the  existence  of  a  truly  in- 
flammatory state,  a  polioencephalitis  which  is  an 
analogue  of  the  poliomyelitis  of  children,  has  received 
little  corroboration  aside  from  his  own  school  of 
workers.  Wernicke  describes  a  case  associated  with 
poliomyelitis  anterior,  but  it  is  a  notable  fact  that  no 
considerable  number  of  similar  cases  are  on  record. 
Since  the  influenza  epidemics  there  have  been  some 


318  PATHOLOGY    OF    EPILEPSY. 

similar  cases  recorded,  chiefly  in  adults;  the  final 
lesion  in  these  cases,  however,  is  very  different  from 
that  of  the  palsy  lesions  of  childhood  (Collier). 

The  role  of  congenital  syphilis  in  causing  these  palsy 
lesions  is  very  subordinate,  if  it  has  any  real  existence 
in  fact.  It  seems  reasonable  that  if  many  of  these 
post-natal  cases  (hemiplegics)  are  to  be  explained  by 
the  occurrence  of  cerebral  hemorrhage,  we  are  also 
to  assume  the  action  of  some  deteriorating  influence 
upon  the  vessels,  such  as  hereditary  syphilis,  which 
renders  them  especially  susceptible.  Weyhe  thinks 
some  cases  are  to  be  thus  explained ;  we  are  in  accord 
with  Sachs,  however,  in  believing  that  there  is  little 
or  no  evidence  in  corroboration  of  this  view-point. 
The  record  of  congenital  syphilis  among  this  class  of 
cases  is  too  slight  to  warrant  us  in  transferring  Weyhe 's 
autopsy  statistics  of  meningeal  hemorrhage  in  con- 
genital syphilis  to  cases  of  infantile  cerebral  palsy  in 
explanation  of  the  primary  lesion.  In  our  opinion, 
it  is  probable  that  embolism  or  thrombosis  following 
the  acute  infectious  diseases  will  explain  most  of  the 
hemiplegias,  while  the  possibility  of  an  acute  infec- 
tious process  in  this  condition  is  not  to  be  lost  sight  of. 
A  large  proportion,  if  not  all,  of  the  diplegias  are  con- 
genital, resulting  from  tedious  and  difficult  birth,  the 
lesion  being  a  hemorrhage  due  to  instrumental  de- 
livery or  to  a  thrombus  formed  in  the  vessels  during  a 
period  of  suspended  animation. 

The  percentage  of  infantile  cerebral  cases  among 
the  epileptics  at  the  Craig  Colony  is  about  8  per  cent. 
Out  of  1872  epileptics  seen  at  the  Vanderbilt  Clinic, 
87  were  hemiplegic  (4  per  cent.).  Of  the  insane 
epileptics  at  Morris  Plains,  N.  J.,  10  per  cent,  were 
hemiplegic.  The  proportion  of  these  cases  to  epilepsy 
in  general  is  best  represented  by  the  figures  from  the 
Vanderbilt  Clinic.  It  is  a  notable  fact,  in  this  con- 
nection, that  the  smaller  the  lesion  in  infantile  cerebral 


GROSS    PATHOLOGY.  319 

palsy,  the  more  severe  the  epilepsy  and  the  greater 
the  liability  to  its  occurrence.  This  fact,  first  sug- 
gested by  Bravais  in  1824,  has  been  revived  by  Sachs 
and  more  recently  corroborated  by  Freud.  It  is 
worthy  of  note  that  in  many  epileptics  of  the  palsy 
type  the  lesion  is  so  slight  that  no  real  palsy  exists 
(infantile  cerebral  palsy  without  palsy,  according  to 
Freud). 

Sclerosis  of  the  cornu  ammonis  is  one  of  the  most 
frequent  gross  conditions  found  in  epilepsy.  It  was 
first  described  by  Mynert  and  subsequently  by 
Sommers  and  Bourne ville,  all  of  whom  laid  much 
stress  upon  the  condition.  More  latterly  Bratz, 
Wooster,  Fere,  and  Chaslin  have  investigated  the 
lesion  and,  while  impressed  with  its  importance,  are 
nevertheless  inclined  to  let  it  gravitate  to  its  proper 
place.  Fere  regards  it  as  merely  an  expression  of  a 
widespread  sclerotic  change  throughout  the  cerebral 
cortex.  The  frequency  of  its  occurrence  varies  con- 
siderably, depending  on  the  class  of  epileptics  observed. 
Bratz  reports  fourteen  instances  in  thirty-two  cases 
examined.  The  degree  of  sclerotic  change  varies 
greatly  and  in  many  instances  the  condition  is  uni- 
lateral. In  stating  our  own  opinion  regarding  this 
lesion,  we  would  amplify  the  opinion  of  Fere  and  say 
that  while  sclerosis  of  the  cornu  ammonis  is  but  a 
local  expression  of  a  widespread  sclerosis  of  the  cortex, 
nevertheless  such  sclerosis  is  of  a  secondary  character. 
This  subject  will  be  further  considered  under  the 
microscopic  section. 

Tumor,  Cyst,  and  Vascular  Lesions. — Tumors  of  the 
brain  giving  rise  to  a  true  epilepsy  are  comparatively 
rare.  On  the  other  hand,  epileptiform  manifestation 
as  a  result  of  tumor  developing  in  the  motor  cortex 
is  not  infrequent.  The  development  of  true  epilepsy 
as  a  result  of  tumor  requires  that  the  tumor  be  located 
in  or  very  near  the  motor  region,  of  comparatively 


320  PATHOLOGY    OF    EPILEPSY. 

small  size,  and  of  slow  growth.  Such  tumors  must 
necessarily  be  non-malignant  and  are  far  more  liable 
to  development  in  the  meninges  than  in  the  brain 
substance. 

The  most  frequent  forms  of  brain  tumor  are  sar- 
comata or  gliomata  which  may  occur  primarily  and 
may  develop  in  the  brain  substance,  or  occur  second- 
arily to  malignant  growths  elsewhere.  Carcinomata 
and  sarcomata  frequently  develop  metastasis  in  the 
brain.  The  epileptiform  manifestations  incidental  to 
such  formations,  however,  do  not  belong  in  the  domain 
of  epilepsy. 

Cyst  formation  in  the  brain  cortex  of  epileptics 
deserves  special  mention.  Old  epileptics  not  infre- 
quently present  small  cysts  in  various  portions  of  the 
brain.  This  seems  to  occur  especially  in  those  epi- 
lepsies developing  in  middle  life.  They  are  probably 
secondary  to  vascular  changes  in  the  smaller  arterioles 
of  the  cortex.  The  changes  described  in  one  of  Collin's 
cases  belong  to  this  class.  In  senile  epilepsy  there  is 
usually  an  extensive  arteriosclerosis,  ultimately  giving 
rise  to  plugging  of  the  vessels  of  the  cortex. 

Following  death  from  a  series  of  severe  epileptic 
seizures  or  from  status  epilepticus,  the  cerebrospinal 
system  often  presents  numerous  small  punctate  hemor- 
rhages. Most  of  these  are  located  in  the  cortex,  but 
they  may  occur  in  any  portion.  Weber  has  recently 
called  attention  to  the  frequency  of  these  hemorrhages 
in  status,  and  has  laid  special  stress  on  their  frequent 
location  in  the  bulb.  He  would  not  only  make  these 
lesions  the  direct  cause  of  death,  but  would  also  thus 
explain  the  transient  paresis  (exhaustion-paralysis) 
following  serial  fits  and  status.  We  do  not  believe 
this  is  warranted,  since,  while  we  have  seen  numerous 
cases  in  which  this  lesion  did  occur,  we  have,  seen 
numerous  others  in  which  it  could  neither  be  demon- 
strated   macroscopically    nor    microscopically.     Cor- 


MICROSCOPIC    PATHOLOGY.  32 1 

tical  punctate  hemorrhages  may  be  a  factor  in  ex- 
plaining certain  slight  permanent  paralyses  following 
status,  nevertheless  these  phenomena  of  disturbed 
motion  are,  for  the  most  part,  to  be  regarded  as  ex- 
haustion phenomena,  as  described  in  another  portion 
of  this  work. 

Epilepsy  as  a  result  of  cerebral  hemorrhage  or  em- 
bolism in  the  adult  is  comparatively  rare,  but  does 
occur.  The  lesions  produced  differ  in  no  particular 
from  those  uncomplicated  by  epilepsy,  a  surface 
hemorrhage  being  more  prone  to  the  production  of 
epilepsy  than  one  in  the  cerebral  substance. 

MICROSCOPIC  PATHOLOGY. 

With  the  beginning  of  the  last  decade  epileptol- 
ogists  were  almost  in  accord  regarding  the  cortical 
origin  of  the  epileptic  fit,  but  as  to  its  underlying 
pathology  in  the  cortex  there  was  great  diversity  of 
opinion.  The  theory  of  the  origin  of  the  fit  in  a  pro- 
nounced cerebral  gliosis  (Fere,  Chaslin,  Sommer) 
was  accompanied  in  greater  or  lesser  degree  by  con- 
ceptions of  its  origin  in  "fine  molecular  changes" 
undemonstrable  by  the  microscope  (Binswanger, 
Gowers,  Jackson)  and  of  a  more  or  less  evanescent 
character.  The  natural  successor  to  this  was  the  auto- 
toxic  theory  (Voisin,  Agostini,  Cololian,  Krainsky), 
the  advocates  of  which  have  ignored  cerebral  changes 
and  sought  to  explain  epilepsy  solely  on  the  basis 
of  an  auto-intoxication.  This  has  been  accompanied 
by  a  movement  on  the  part  of  experimental  physiol- 
ogists and  pathologists  (Prus,  Hering,  Redlich,  Bis- 
choff,  Rothman,  von  Bechterew)  who  have  attempted 
the  determination  of  the  nature  of  the  spasm,  its  exact 
seat  of  origin  and  mode  of  transmission.  We  may  ask 
ourselves  at  the  outset  what  these  various  groups  of 
workers  have  accomplished. 

The  first  group  of  observers  has  demonstrated  the 


322  PATHOLOGY    OF    EPILEPSY. 

extreme  frequency  of  cortical  gliosis  in  epilepsy.  They 
have  not  demonstrated  its  universal  occurrence,  but 
we  shall  have  occasion  to  note  further  on  that  there 
is  some  reason  for  assuming  its  unexceptional  occur- 
rence in  cases  of  any  considerable  duration  and  sever- 
ity. Some  of  these  observers  (Alzheimer,  Bleuler) 
have  also  demonstrated  the  great  frequency  of  cortical 
cell  changes,  such  as  chromatolysis,  in  almost  all  of 
their  cases;  however,  there  has  also  been  a  tendency 
to  emphasize  the  role  of  gliosis  in  epilepsy,  and  there 
has  been  much  theorizing  on  the  possibility  of  the 
glial  overgrowth  being  the  essential  underlying  factor. 

The  second  group  of  observers  has  recognized  the 
insufficiency  of  the  findings  and  theories  of  the  first 
group,  and  has  attempted  to  get  nearer  to  a  real 
explanation  of  the  facts  by  the  enunciation  of  another 
theory  launched  partially  in  the  realm  of  dynamics. 
They  have  demonstrated  nothing  regarding  this  theory 
and  its  relationship  to  the  pathology  of  epilepsy. 

The  third  group  of  observers  has  recognized  also 
the  insufficiency  of  the  known  microscopic  findings  in 
explaining  the  pathology  of  epilepsy,  and  has  entered 
the  field  of  chemistry  and  toxicology  in  search  of  an 
explanation.  They  have  demonstrated  the  heightened 
toxicity  of  certain  secretions  and  excretions  of  the 
epileptic,  and  have  attempted,  without  success,  the 
demonstration  of  the  exact  substance  entering  into 
the  intoxication.  That  the  toxicity  of  certain  of  the 
body  fluids  is  greatly  heightened  in  epilepsy,  seems 
well  established,  but  the  exact  role  of  these  toxic 
substances  in  producing  the  epileptic  fit  has  not  as 
yet  been  proved.  It  is  to  be  noted  that  this  work 
is  still  in  its  preliminary  stage,  and  that  experimenters 
have  not  progressed  beyond  the  demonstration  of  the 
toxicity  of  certain  of  the  body  fluids.  The  work  of 
this  group  of  observers  will  be  further  considered  under 
pathogenesis. 


MICROSCOPIC    PATHOLOGY.  323 

The  fourth  group  of  observers  has  done  much  to 
push  forward  our  knowledge  of  the  essential  nature 
of  epilepsy.  Epilepsy  may  be  due  to  a  toxin  or  auto- 
toxin,  but  the  manner  of  its  action  must  remain  a 
mystery,  unless  we  can  know  something  of  the  nature 
of  the  fit.  The  portions  of  the  cortex  and  the  cell 
elements  involved,  the  nature  of  the  fit,  and  the  tracts 
over  which  it  is  transmitted — all  these  have  been  prob- 
lems which  these  workers  have  approached  with  more 
or  less  success.  The  bearing  of  their  work  upon  the 
microscopic  pathology  of  epilepsy  will  warrant  us  in 
presenting  some  portions  of  it  more  in  detail. 

Prus  has  recently  undertaken  the  demonstration  of 
the  paths  over  which  the  fit  generalizes,  with  a  view 
to  determining  the  role  of  the  sensory  and  motor 
elements  in  the  production  of  the  spasm.  In  order 
to  do  this  he  severed  the  pyramidal  tracts  on  both 
sides  at  various  levels  from  the  internal  capsule  to 
the  spinal  cord;  notwithstanding  this,  however,  the 
development  and  generalization  of  the  fit  were  not 
interfered  with  on  electrically  irritating  the  cortex. 
From  this  he  concluded  that  the  fit  in  epilepsy  did  not 
generalize  by  means  of  the  pyramidal  tracts.  This 
was  further  supported  by  the  following  experiment: 
After  cutting  through  everything  in  the  peduncles 
except  pyramidal  and  pontine  fibers,  he  found  that  he 
was  not  able  to  produce  a  fit  on  electric  irritation  of  the 
cortex.  If  the  motor  cortex  was  irritated  the  corre- 
sponding muscle  groups  contracted,  but  no  epilepti- 
form manifestation  followed.  From  this  he  concluded 
that  neither  the  pyramidal  tracts,  the  fronto-bridge 
tracts,  nor  the  temporo-occipito-bridge  tracts  take 
any  part  in  the  transmission  of  the  impulse  in  epilepsy ; 
that  the  impulse  is  transmitted  by  means  of  tracts 
which  lie  entirely  without  these,  and  that  these  tracts 
course  in  the  dorsal  portion  of  the  peduncles. 

Hering,  and  more  recently  Bischoff,  have  each  cor- 


324  PATHOLOGY    OF    EPILEPSY. 

roborated  in  large  measure  this  work  of  Pms.  The 
work  of  Starlinger,  who  demonstrated  the  non-exist- 
ence of  paralysis  in  dogs  in  which  the  pyramidal  tracts 
were  destroyed,  was  in  a  measure  anticipatory  to 
that  of  Prus,  in  proving  the  existence  of  tracts  other 
than  the  pyramidal  tracts  capable  of  transmitting 
motor  impulses.  Recently  the  more  exact  identity 
of  these  tracts  has  been  proved  by  Redlich,  Rothman,* 
and  others,  and  the  original  findings  of  Prus  have  in  the 
main  been  established.  Having  demonstrated  to  his 
own  satisfaction  that  the  fit  generalized  over  other  than 
the  ordinary  motor  paths,  Prus  undertook  the  demon- 
stration of  the  nature  of  the  fit;  i.  e.,  whether  irrita- 
tion of  the  sensory  or  of  the  motor  elements  of  the 
cortex  induced  the  epileptic  spasm.  In  order  to 
elucidate  this  question,  he  painted  the  cortex  with 
various  agents  which  impair  the  sensibility  of  the 
sensory  elements.  While  cocain  was  applied  locally 
no  fit  could  be  produced  on  electric  irritation  of  the 
cortex,  but  the  individual  muscle  groups  in  the  periph- 
ery would  still  respond  on  stimulating  corresponding 
portions  of  the  cortex.  Bromids  diminished  the  irrit- 
ability of  the  cortex.  He  concludes  that  the  starting 
point  of  the  fit  in  epilepsy  is  either  in  the  end  tufts 
of  sensory  nerves  in  the  cortex  or  in  the  sensory  cells 
of  the  cortex  and  not  in  the  motor  cells  or  fibers.  This 
fact  is  corroborated  by  clinical  evidence  furnished  by 
the  decided  influence  of  the  bromids  upon  epilepsy  in 
general  (explainable  by  way  of  its  effect  upon  the  sen- 
sory elements  of  the  cortex),  and  by  the  fact  that  the 
initial  manifestation  of  epilepsy  is  often  an  aura  which 
always  belongs  in  the  sensory  realm. 

The  preceding  facts  are  very  suggestive  that  epi- 
leptic convulsions  are  a  manifestation  of  a  diseased 
state  of  the  sensory  elements  of  the  cortex. 

*  The  fasciculus-sulco-marginalis  descendens  and  the  fasciculus-rubro- 
spinalis  (v.  Monakow)  correspond  to  the  "extra-pyramidal  tracts"  of  Prus. 


Plate  ig. 


Fig.  2. 


Fig. 


Fig-  4- 


Fig.  i. — The  lesion  of  a  severe  case  of  infantile  cerebral  hemiplegia 
involving  the  whole  left  cerebral  hemisphere;  the  right  cerebellar  hemi- 
sphere is  secondarily  atrophied. 

Fig.  2. — Cells  lying  in  the  outermost  portion  of  the  second  cortical 
layer  (case  of  status),  showing  two  abstracted  nucleoli  (a  and  b).  Cells 
swollen  and  granular;  the  nucleus  and  its  limitations  poorly  defined. 

Fig.  3. — Group  of  cells  lying  in  the  lower  portion  of  the  second  cortical 
layer  (case  of  status),  showing  cells  greatly  swollen  and  granular  with 
abstracted  nucleolus  (a)  lying  without. 

Fig.  4. — Group  of  normal  nerve  cells,  second  cortical  layer.  Section 
made  from  a  case  of  accidental  shooting  in  which  the  patient  died  in- 
stantly. 

Xissl  stains.     Photomicrographs  X   1000. 


MICROSCOPIC    PATHOLOGY.  325 

A  demonstration  of  the  particular  sensory  elements 
involved  would  strengthen  this  hypothesis.  We  are 
confronted,  then,  by  the  question:  What  particular 
elements  of  the  cortex  are  involved  in  epilepsy,  and 
are  such  elements,  broadly  speaking,  sensory  or  motor 
in  character?  The  results  of  our  study  of  the  cortex 
of  twenty  epileptics  from  the  Craig  Colony,  with  this 
question  in  mind,  warrant  the  following  statements : 

The  most  striking  changes  presented  by  the  cortex  of 
the  epileptic  are  found  in  the  cells  of  the  second  cortical 
layer,  cells  distinctly  sensory  in  type.  In  patients 
dying  during  a  period  of  status  epilepticus  these 
changes  are  most  decided.  The  cells  are  swollen  in 
many  instances  to  twice  their  normal  size,  the  nucleus 
being  especially  large  and  granular,  with  indistinct 
outline.  The  limitations  of  the  nucleus  are  often 
difficult  to  determine,  the  chromatic  substance  has 
almost  disappeared  from  the  body  of  the  cell,  and  this 
portion  of  the  cell  appears  ragged  and  poorly  outlined. 
The  most  striking  changes  are  found  in  the  nucleus. 
In  addition  to  being  granular,  swollen,  and  poorly 
outlined,  the  nucleolus  is  often  absent,  having  been 
abstracted  from  the  nucleus  in  the  process  of  section- 
making  (Plate  19,  Figs.  2  and  3).  This  occurs  in  status 
cases  two  or  three  hundred  times  more  frequently  than 
in  sections  of  normal  brain  (Plate  19,  Fig.  4). 

The  significance  of  these  changes  is  obvious.  The 
most  important  alteration  is  found  in  the  nucleus  of 
the  cell  of  the  second  cortical  layer  and  other  cells 
of  that  type.  The  change  affects  the  intranuclear 
network,  destroying  it  and  rendering  the  nucleolus  a 
loose  body  within  the  nucleus,  so  that  it  is  readily 
abstracted  from  it  in  making  the  section.  The  ulti- 
mate disappearance  from  the  cortex  of  cells  so  seriously 
altered  is  to  be  inferred.  The  particular  involve- 
ment of  the  nucleus  in  this  process  is  a  fact  of  the 
first  importance.     Biologic  facts  teach  us  that  "the 


326  PATHOLOGY    OF    EPILEPSY. 

formative  power  of  the  cell  centers  in  the  nucleus" 
and  that  it  is  therefore  "  to  be  regarded  as  the  especial 
organ  of  inheritance ' ' ;  that  ' '  it  plays  an  essential 
role  in  chemical  synthesis";  that  "digestion  and 
absorption  of  food  and  secretion  cease  with  its  removal 
from  the  cytoplasm"  and  that  "fragments  of  proto- 
plasm deprived  of  the  nucleus  die ' '  (Wilson,  Ver- 
worn).  When,  therefore,  morbid  processes  attack 
the  nucleus,  the  vital  center  of  the  cell,  the  portion 
essential  to  its  life  is  threatened ;  if  this  continues  for 
a  period  the  cell  is  ultimately  destroyed.  We  are 
justified  in  assuming,  therefore,  that  the  essential 
poison  in  epilepsy  is  a  nuclear  poison,  which  shows  a 
special  predilection  for  certain  delicately  constituted 
cells  of  the  cerebral  cortex,  typical  of  the  second  layer. 

Many  authors  have  described  chromatolysis  fol- 
lowing the  epileptic  seizure.  It  is  always  present 
following  serial  fits  and  is  especially  marked  in  status 
cases,  in  which  condition  it  is  often  so  decided  that 
the  large  Betz  cells  of  the  motor  cortex  appear  like 
denuded  cell  remnants,  the  body  of  the  cell  being 
greatly  shrunken.  Changes  of  this  character  are  always 
general. 

In  the  light  of  recent  investigations  (Marinesco, 
Lugaro,  Ewing)  we  are  to  regard  these  changes  as 
nutritional  in  character,  brought  about  chiefly  by  the 
suspension  of  function  on  the  part  of  the  nucleus  which, 
as  we  have  previously  mentioned,  presides  over  the 
processes  of  nutrition  and  assimilation  within  the  cell. 

An  extensive  invasion  of  the  cortex  with  leukocytes 
is  a  very  frequent  condition,  especially  following  status 
and  serial  fits.  This  was  especially  marked  in  some 
of  our  own  cases,  leukocytes  being  often  found  in  the 
pericellular  and  perivascular  lymph  spaces  and  through- 
out the  cortical  substance.  It  is  highly  probable  that  the 
phagocytic  property  of  the  leukocyte  is  here  called  into 
play  to  remove  the  products  of  tissue  metamorphosis. 


MICROSCOPIC    PATHOLOGY.  327 

A  neuroglia  hyperplasia  is  a  very  frequent  micro- 
scopic change  in  epilepsy,  and  was  especially  marked 
in  some  of  our  cases.  It  is  usually  manifested  by  a 
very  pronounced  glial  overgrowth,  especially  in  the 
outer  cortical  layer.  The  outer  layer  often  appears 
of  unusual  depth  and  the  neuroglia  fibers  dip  down 
deeply  into  the  cortex  from  cells  lying  in  the  outer 
layer.  There  is  often  a  subcortical  glial  overgrowth, 
especially  pronounced  in  some  imbecile  epileptics,  in 
whom  a  pronounced  general  gliosis  is  common. 

In  the  light  of  what  has  gone  before,  this  glial  over- 
growth is  easily  explained.  The  nerve  cell  once 
destroyed  is  never  replaced.  The  vacancy  caused  by 
its  disappearance  must  be  taken  by  cells  capable  of 
proliferation.  It  has  been  experimentally  proved  that 
the  neuroglia  will  proliferate  in  response  to  chemical 
irritation.  The  great  increase  in  the  neuroglia  in 
epilepsy  occurs,  therefore,  in  all  probability,  in  re- 
sponse to  (a)  the  action  of  toxic  elements  peculiar  to 
epilepsy  upon  the  neuroglia  cell  direct,  and  (b)  as  a 
direct  sequence  of  nerve  cell  destruction.  With  im- 
proved methods  neuroglia  proliferation  will  probably 
be  demonstrated  in  every  case  of  epilepsy  of  any  con- 
siderable duration  and  severity. 

The  question  of  the  phagocytic  function  of  the  neu- 
roglia is  suggested  by  some  recent  work  of  Mallory. 
He  has  shown  that  many  cells  of  endothelial  type  and 
origin  become  markedly  phagocytic  in  response  to  the 
action  of  certain  toxic  substances.  This  theory  seems 
possible,  especially  since  the  suggestion  of  W.  Ford 
Robertson  of  two  distinct  types  of  cells  in  the  neurog- 
lia— one  of  epiblastic  and  the  other  of  mesoblastic 
origin.  He  also  points  out  that  the  mesoblastic  cell 
is  phagocytic.  It  would  seem  possible,  therefore,  that 
we  may  have  cells  now  considered  as  belonging  to 
the  neuroglia  that  become  phagocytic  under  provo- 
cation. 


328  PATHOLOGY    OF    EPILEPSY. 

The  conclusion  seems  warranted  that  epilepsy  is  a 
disease-state  of  the  sensory  elements  of  the  cortex, 
and  that  the  impulses  constituting  the  discharge 
phenomena  are  peculiar  to  such  disease-states  and  are 
transmitted  over  other  than  the  ordinary  motor  paths. 
The  elements  of  the  cortex  most  seriously  involved 
are  certain  sensory  cells  of  the  second  cortical  layer, 
some  of  which  are  destroyed  during  the  epileptic  pro- 
cess. 

PATHOGENESIS. 

The  presence  of  a  predisposition  is  not  sufficient  to 
account  •  for  epilepsy,  hence  the  necessity  of  invoking 
some  agent  which  excites  the  organic  cellular  anomaly 
of  the  cortex  to  morbid  activity.  Even  in  traumatic 
cases  it  is  not  necessary  to  discard  this  explanation. 
Indeed,  in  such  cases  a  faulty  chemotaxis  of  the  cor- 
tical cells  themselves  probably  constitutes  the  inciting 
factor.  From  modern  data,  our  present  view-point 
that  the  pathogenic  agent  rests  in  the  domain  of  chemi- 
cal pathology  is  logical,  but  it  must  point  the  way  more 
definitely  before  further  progress  is  possible. 

We  are  permitted  therefore  to  make  only  the 
broadest  generalizations  as  to  the  inciting  agent  in 
epilepsy.  Although  the  chemical  studies  are  but  ten- 
tative, they  are  suggestive.  The  blood,  investigated 
by  Ceni,  Herter,  Donath,  Cololian;  the  urine  by 
Agostini,  Voisin,  Peron,  Mairet  and  Vires,  K.  von 
Quonge,  and  Saike;  the  gastric  contents  by  Bond, 
Agostini,  Rachford,  Putnam  and  Pfaff;  the  sweat  by 
Cobitts  and  Movrojainnis,  and  finally  the  secretions 
of  the  ductless  glands,  particularly  the  thymus,  by 
Ohlmacher  and  many  others,  have  been  and  are  still 
under  investigation. 

In  general  terms  it  may  be  said  that  the  majority 
of  good  observers  in  chemical  pathology  believe  that 
blood,  sweat,  urine,  and  gastric  contents  are  hypotoxic 


INTERPRETATION    OF    PATHOLOGIC    FINDINGS.       329 

in  the  inter-paroxysmal  state  of  epilepsy;  hypertoxic 
just  before  the  fit,  at  the  time  of  and  for  a  variable 
period  just  after  the  tit.  There  is  no  agreement, 
however,  upon  the  agent  or  agents  producing  this 
alteration  in  toxicity.  Some  believe  it  due  to  car- 
bamate of  ammonium  (Krainsky,  Weber),  others 
find  cholin  and  neurin  which  they  believe  to  play  a 
role  in  the  causation  (Donath) ;  but  the  presence  of  the 
two  latter  agents  is  probably  due  to  the  same  cerebral 
disintegration  in  epilepsy  as  in  general  paresis  and 
senile  dementia,  where  they  are  present  in  great  excess 
(Mott,  Halliburton). 

Ceni  claims  to  have  demonstrated  an  autocytotoxin 
and  an  anti-autocytotoxin  in  the  epileptic  blood  which 
does  not  exist  in  a  free  state  in  the  plasma,  but  is 
latent  chiefly  in  the  blood-cells  from  which  it  is  set 
free  at  the  convulsive  period  by  a  ferment. 

Xanthin  and  paraxanthin  have  been  found  in 
epilepsy  as  well  in  the  migraines  (Rachford),  but 
other  investigators  while  finding  it  in  some  cases  do 
not  find  it  in  others  and  deny  that  it  plays  an  impor- 
tant role  in  the  etiology  of  either  disease  (Putnam 
and  PfafT).  The  disease  has  been  attributed  to  a 
leukomain  poisoning  (Bond  and  Agostini),  to  acetone 
(Deutsch,  von  Jaksch,  and  Futcher),  and  to  a  dimin- 
ished alkalinity  of  the  blood  (Lui  and  Pio  Galante). 

Extensive  clinical  work  under  control  and  fixed 
conditions  has  yet  to  be  done.  From  the  nature  of 
the  cortical  cell  changes  we  have  a  right  to  expect  that 
the  inciting  agent  or  agents  will  be  very  active  nuclear 
poisons. 

CLINICAL  INTERPRETATION  OF  THE  NEWER  PATHOLOGIC 

FINDINGS. 

The  remote  relationship  of  previously  discovered 
gross  brain  lesions  to  that  of  epilepsy  has  been  fully 
dealt  with  elsewhere,  and  we  shall  concern  ourselves 


330  PATHOLOGY    OF    EPILEPSY. 

only  with  correlating  clinical  data  with  the  newer 
facts  in  pathology  and  particularly  with  the  cortical 
cell  changes  already  described. 

The  constancy  of  the  cortical  lesion  in  all  the  varying 
states  of  epilepsy,  from  the  mildest  type  to  the  most 
rapidly  fatal  status,  warrants  broad  generalization  in 
regard  to  the  nature  of  epilepsy  itself. 

That  the  essential  phenomena  of  the  disease  are 
sensory  in  character,  and  that  the  motor  manifestation 
is  secondary,  has  now  the  support  (i)  of  the  logical 
hypothesis  of  Hughlings  Jackson  in  which  the  second 
layer  cell  has  inhibitory  relationship  to  the  motor  cell, 
and  also  acts  as  a  promoter  and  regulator  to  its  activity. 
The  physiologico-pathologic  work  upon  animals  by 
Prus  and  others,  and  (2)  the  pathologic  evidence  in 
the  histo-cytologic  examination  of  the  cortex  of 
epileptics  at  the  Craig  Colony.  The  disease  may  be 
considered  therefore  a  highly  organized  sensory  motor 
reflex  of  the  cerebral  cortex. 

The  sedative  action  of  bromids,  experimental  and 
clinical,  furnishes  therapeutic  proof  that  the  afferent 
side  of  this  reflex-arc  is  operated  upon  either  peripher- 
ally, or,  what  seems  more  probable,  upon  the  sensory 
type  of  cells  in  the  cortex  itself.  Bromids  control  the 
fits  by  reducing  the  intensity  of  afferent  impulses  to 
motor  cells ;  the  latter  are  without  doubt  immediately 
responsible  for  the  muscular  convulsion  in  the  fit. 
Furthermore,  when  the  bromids  produce  acute  or 
chronic  poisoning  the  state  produced  is  quite  com- 
parable to  the  immediate  and  remote  effects  of  the 
disease  itself,  and  as  a  consequence  they  have  been 
charged  with  the  mental  stigma  of  the  disease  (pro- 
gressive dementia).  The  bromids  acting  upon  the 
sensory  elements  aid  cerebral  inhibition.  The  fact 
that  they  are  of  little  avail  in  brain  diseases  more  or 
less  definitely  motor  in  character,  such  as  myoclonus, 
paralysis  agitans,  and  the  post-hemiplegic  disorders  of 


INTERPRETATION    OF    PATHOLOGIC    FINDINGS.       33  I 

motility,  is  corroborative  of  their  primary  physiologic 
action  upon  the  sensory  cortical  cells. 

The  anatomic  evidence  of  the  persistence  of  the 
large  pyramids  of  the  cortex  which  are  largely  motor 
in  function,  is  proof  of  the  autonomy  of  these  elements. 
They  may  and  often  do  undergo  marked  shrinkage  in 
epilepsy,  but  are  quickly  restored  to  their  former  inter- 
paroxysmal  stage  in  the  rest  period.  As  they  never 
disappear  from  the  cortex  in  the  same  degree  as  those 
of  the  sensory  type,  paralyses  other  than  that  of  the 
transitory  exhaustion  type  (and  another  form  to  be 
considered)  are  of  rare  occurrence. 

The  evidence  that  epilepsy  is  a  diffuse  lesion  of  the 
entire  cortex  is  of  practical  moment  and  aids  much  in 
-explaining  the  complex  and  bizarre  symptoms,  and 
also  the  inutility  of  narrow  principles  in  treatment. 
It  is  not  unlikely  that  further  research  may  indicate 
certain  areas  of  the  cortex  which  are  most  diseased  in 
special  cases,  particularly  those  portions  of  the  cortex 
most  highly  specialized  in  sensory  and  sensori-psychic 
functions.  There  is  as  yet,  however,  no  adequate 
pathologic  evidence  for  this. 

Clinical  facts  constantly  urge  that  attention  be 
directed  to  the  sensory  elements.  An  order  of  mus- 
cular march  in  the  fits  shows  only  the  successive  order 
of  discharge  in  the  motor  centers;  it  usually  remains 
identically  the  same  for  years,  yet  we  know  that  the 
disease,  if  unrelieved,  steadily  undergoes  important 
modifications,  shown  in  a  continuous  destruction  of 
cortical  elements.  Turning  from  the  motor  symptoms 
to  those  of  the  sensory  we  find  that  the  aura,  the  loss 
of  consciousness,  and  the  degree  and  character  of 
mental  changes,  are  the  sensory  factors  considered 
in  diagnosis  and  prognosis.  Some  physio-psychologic 
means  of  recording  the  latter  would  aid  much  in 
estimating  the  degree  and  character  of  cortical  de- 
struction.    The  failure  of  surgical  interference,  even 


S32  PATHOLOGY    OF    EPILEPSY. 

when  focal  symptoms  still  remain  as  shown  elsewhere 
in  this  work,  is  explained  largely  because  the  cortical 
changes  are  diffuse,  and  in  other  areas  and  in  other 
cortical  elements  than  those  classed  more  especially  as 
motor  in  function.  A  coincidence,  however,  of  damage 
to  both  sensory  and  motor  elements  in  the  Rolandic 
area  in  traumatic  epilepsy  explains  largely  the  good 
results  in  surgical  interference  in  acute  cases  where  the 
predisposition  is  at  a  minimum. 

The  most  serious  clinical  phase  of  the  cortical 
pathology  is  due  to  the  ultimate  disappearance  of  the 
cortical  cells;  their  destruction  explains  many  of  the 
permanent  symptoms  of  the  disease,  especially  the  slow- 
ness, awkwardness,  and  incoordination  of  muscle  move- 
ments, and  the  progressive  mental  failure  (dementia) 
which  is  seen  in  so  many  epileptics.  The  disorder 
of  motility  in  chronic  cases  amounts  to  a  paralysis 
in  many  instances.  The  local  and  general  exhaus- 
tion present  after  local  or  general  fits  (especially  seen 
in  those  parts  which  participate  most  in  the  convul- 
sion), are  true  exhaustion-paralyses  in  type,  congeners 
of  paralyses  from  destructive  lesions  of  motor  cells 
and  tracts,  but  the  sluggish,  awkward,  and  incoordinate 
movements  present  in  chronic  epilepsy  are  really 
consequent  upon  cell  destruction  in  the  second  layer, 
which  leaves  the  motor  elements  indefinitely  informed 
of  the  sensations  to  which  they  should  respond.  The 
damage  or  loss  of  sensory  cells  not  only  permits 
cortical  motor  cell  overaction,  as  seen  in  the  fit,  but 
also  leaves  these  motor  elements  uninformed  of  the 
normal  nature  and  character  of  movements  required. 
Analogous  theoretic  explanations  were  first  urged  for 
the  ataxia  of  tabetics  by  Jackson.  The  anatomico- 
pathologic.  difference  is  that  in  ataxia  the  destruction 
is  anterior  in  point  of  time  in  the  sensorimotor  reflex- 
arc.  The  dementia  of  epilepsy  is  analogous  and  is 
usually  commensurate  with  the  defective  motility;  it 


INTERPRETATION    OF    PATHOLOGIC    FINDINGS.       333 

has  been  erroneously  ascribed  as  the.  cause  of  the  latter 
rather  than  an  incident  and  coincident  of  it. 

Finally,  the  modern  pathology  of  epilepsy  gives 
sufficient  ground  for  the  present  broad  but  empirical 
treatment  of  the  disease,  which  consists  largely  in 
overcoming  hereditary  tendencies  as  far  as  possible, 
and  excluding  toxic  and  autoxic  agents  and  administer- 
ing a  carefully  detailed  plan  of  living  plus  such  degrees 
of  sedation  as  may  be  necessary  in  individual  cases. 
In  the  light  of  the  pathogenesis  (although  as  yet  it 
but  foreshadows  its  fruition)  and  the  histo-pathologic 
changes  already  known,  with  their  certain  results  in 
impairment  of  normal  cerebral  functions  if  not  checked, 
the  importance  of  the  most  comprehensive  and  early 
treatment  is  obvious. 

The  missing  links  in  our  knowledge  of  epilepsy  are 
its  pathogenetic  agents  and  the  organic  anomaly  of  the 
cortex  which  constitutes  its  predisposition;  these  two 
factors  still  hold  the  mystery  of  frequent  relapses. 
The  gap  between  its  terminal  gliosis  and  the  toxic 
and  autoxic  agents  has  been  narrowed  by  recent 
knowledge  of  the  initial  cortical  cell  changes,  which 
particularly  concern  the  nucleus. 

We  are  warranted  in  drawing  the  following  conclu- 
sions regarding  the  pathology  of  epilepsy : 

1.  Epilepsy  is  a  cerebral  disease  attended  and  fol- 
lowed by  profound  and  diffuse  cortical  degeneration. 

2.  The  morbid  changes  concern  chiefly  the  destruc- 
tion of  the  nuclei  of  the  cells  of  the  sensory  type  from 
which  the  primary  departure  of  the  disease  originates. 
Its  terminal  pathology  is  a  progressive  gliosis  more  or 
less  marked  and  diffuse. 

3.  Epilepsy  is  essentially  a  sensory  phenomenon 
with  a  motor  manifestation. 

4.  Its  etio-pathology  rests  with  a  variety  of  toxic  or 
autotoxic  agents  not  as  yet  definitely  isolated  or 
determined. 


334  PATHOLOGY    OF    EPILEPSY. 

5.  The  disease  is  engrafted  upon  a  cortical  organic 

cellular  anomaly  which  is  induced  largely  by  a  faulty 

heredity,  the  exact  anatomic  nature  of  which  is  not 

known. 

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Agostini:  "Rev.  Sper.  di  Freniatria,"  1896. 

Alzheimer:  "Monatschr.  f.  Psychiatrie  und  Neurologie,"  1898,  iv. 

v.  Bechterew:  "Neurol.  Centralblatt,"  1895,  xiv. 

Bischoff:  "Wiener  klin.  Woch.,"   1899,  xxxix.     "Jahrbuch  f.  Psych.," 

1901. 
Binswanger:  "Specielle  Path.  u.  Therapie"   (Nothnagel),  Bd.  xn,  1899. 
Bleuler:  "Munch,  med.  Woch.,"  1895,  xlii,  33. 
Bourneville:  "Recherches    sur    1' epilepsie,"    etc.     Published    annually, 

1892-97. 
Bourneville  and  Sollier:  "Prog,  med.,"  xvi. 
Bra:  "Revue  neurolog.,"  May  30,  1902. 
Bratz:  "Arch.  f.  Psychiatrie,"  xxxi,  3. 
Bratz  and  Hebold:  "Deutsche  med.  Woch.,"  1902,  36. 
Bresler:  "Neurol.  Centralblatt,"  1896,  xv. 
Caro:  "Deutsche  med.  Woch.,"  1900,  xix. 
Ceni:  "Neurol.  Centralblatt,"  March  19,  1902. 
Chaslin:  "Die  Epilepsie,"  Binswanger. 
Christian:  "Journal  of  Mental  Science,"  1891,  xxxvn. 
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Oct.,  1902. 

"Epilepsy,"  "Boston  Medical  and  Surgical  Journal,"  Vol.  cxlviii, 

No.  17. 

"  Status    Epilepticus,"    "Am.  Journal  of   Insanity,"    Oct.,    1903, 

Jan.  and  April,  1904. 

Claus:  "Brux,"  1896. 

Collier:  "Brain,"  1899. 

Collins:  "Journal  of  Nervous  and  Mental  Diseases,"  1896,  xxi. 

Cololian:  "Arch,  de  neurologie,"  March,  1899. 

Couvreur:  "Die  Epilepsie,"  Binswanger. 

Deutsch:  "Wiener  med.  Woch.,"  1900,  II. 

Eurich:  "Brain,"  1897. 

Fere:  "Die  Epilepsie,"  Binswanger. 

Freud:  "Specielle  Path.  u.  Therapie"   (Nothnagel),  Bd.  ix,  2. 

Galante:  "British  Med.  Journal,"  1899,  xx. 

Gowers:  "Epilepsy,"  London,  1901. 

Hering:  "Wiener  klin.  Woch.,"  August  17,  1899. 

Herter:  "Journal  of  Nervous  and  Mental  Diseases,"  1899,  xxvi.     "Med. 

Record,"  1899,  xx. 
Jackson:  "Lumlian  Lectures"  (London),  "Lancet,"  1890. 
Juliusberger:  "Neurol.  Centralblatt,"  1896. 


REFERENCES.  335 

Kowalewsky:  "Centralblatt  f.  Nervenheilkunde,"  1897. 

Krainsky:  "Allg.  Zeitschr.  f.  Psych.,"  Bd.  liv. 

Lewis,  Bevan:  "Mental  Diseases,"  1899. 

Lorenz:  "Status  Epilepticus,"  Kiel,  1890. 

Mairet  and  Vires:  "Soc.  de  Biol.,"  1898. 

Marie:  "Die  Epilepsie,"  Binswanger. 

Marinesco:  "Medical  Orient,"  Paris,  1898,  xi. 

Mavrojainnis :  "Revue  de  Psych.,"  July,  1898. 

Mondino:  "Civr.  Internaz.  d.  sc.  Med.  Napoli,"  1896,  xviii. 

Mott:  "Arch,  of  Neurol.,"  1900. 

Muchand:  "Bull,  et  Mem.  de  la  Soc.  Anat.  de  Paris,"  July,  1902. 

Mynert:  "Die  Epilepsie,"  Binswanger. 

Nawratski  and  Arndt:  "Psych.  Verein  zu  Berlin,"  June,  1899. 

Ohlmacher:  "Transactions  of  Ohio  State  Med.  Soc,"  Cleveland,  1898. 

"Bulletin  of  Ohio  State  Hospital  for  Epileptics,"  1898,  1899. 

Oppenheim:  "Nerv.  Krankheiten,"  1899. 

Osler:  "Text-book  of  Medicine,"  1892. 

Ossipow:  "Deutsche  Zeitschr.  f.  Nervenheilkunde,"  Bd.  xv    1  and  2. 

Probst:  "Deutsche  Zeitschr.  f.  Nervenheilkunde,"   Bd.  xv,  3  and  4. 

Prtjs:  "Wiener  klin.  Woch.,"  1898,  xi. 

Putnam  and  Pfaef:  "Assoc.  Amer.  Physicians,"  1900. 

Rachford:  "Amer.  Journal  of  Med.  Sciences,"  cxv,  p.  436. 

Redlich:  "Monatschr.  f.  Psych,  u.  Neurolog.,"  Bd.  v,  1899. 

Robertson,  W.  F.:  "Edinburgh  Hospital  Reports,"  Vol.  v,  1898. 

"Path.  Ment.  Dis.,"  Edinburgh,  1900. 

Roncoroni:  "Arch,  di  Psychiatria,"  1900,  xxi. 
Rossi:  "Rev.  Sper.  di  Freniatria,"  xxiv. 
Rothmann:  "Zeitschr.  f.  klin.  Med.,"  xliv. 
Sachs:  "KUn.  Vortrage,"  Leipsic,  1902. 

Sachs  and  Peterson:  "Journal  of  Nervous  and  Mental  Diseases,"  1890. 

Sommer:  "Die  Epilepsie,"  Binswanger. 

Starlinger:  "  Jahrbuch  f.  Psych,  u.  Neurolog.,"  Bd.  xv,  1897. 

Tedeschi:  "Rev.  Sper.  di  Freniatria,"  1894,  xx. 

Van  Gieson:  "Med.  Record,"  N.  Y.,  April  29,  1893. 

Verworn:  " General  Physiology,"  1899  (Lee's  translation). 

Weber:  "Munch,  med.  Woch.,"  1898,  xlv. 

"Pathology  and  Pathogenesis  of  Epilepsy,"  Jena,  190 1. 

Wilson:  "The  Cell,"  New  York,  1896. 

Wright:  "Brain,"  1898,  p.  186. 


CHAPTER  XIII. 
THE  GENERAL  TREATMENT  OF  EPILEPSY. 

Control  of  Patient  of  First  Importance.  Regulation  of  the  Patient's  Habits 
and  Diet.  The  Value  of  Proper  Exercise.  The  Purpose  and  Scope  of 
Medico-pedagogic  Treatment.  The  Young  Epileptic's  Especial  Demand 
for  Education  and  Training.  The  Mental,  Moral,  and  Physical  Failure 
of  the  Epileptic  without  Care. 

The  treatment  of  epilepsy  lies  along  three  distinctive 
lines :  General,  Medical,  and  Surgical,  and  we  will  con- 
sider them  in  the  order  named. 

In  speaking  of  the  general  treatment  of  epilepsy,  we 
refer  more  particularly  to  the  treatment  of  the  epileptic 
himself  than  to  the  treatment  of  his  disease.  The  im- 
portance of  the  former  has  been  steadily  increasing 
since  the  epileptic  first  came  under  especial  care  in 
this  country  in  institutions  designed  for  his  needs, 
twelve  or  fifteen  years  ago.  Up  to  that  time  the 
medical  treatment  of  the  disease  was  held  to  be  of 
paramount  importance,  since,  indeed,  it  was  the  only 
one  then  known  to  be  at  the  physician's  command. 
But  now,  while  drugs  play  a  conspicuous  and  valuable 
part,  they  are  regarded  by  the  best  among  those 
whose  familiarity  with  epilepsy  is  greatest,  as  often 
falling  short  of  fully  meeting  the  requirements  in  all 
cases,  so  that  the  aid  of  other  agencies  must  be  evoked. 
These  will  be  described  in  detail  in  the  present  chapter, 
for  their  value  is  clearly  beyond  dispute,  while  the 
knowledge  of  their  use,  variously  modified  as  they 
must  be  to  meet  changing  types  of  cases,  is  not  nearly 
so  universal  as  it  ought  to  be. 

To  be  sure,  the  physician  in  general  practice  is 
often    handicapped    by    his    inability    to    control    the 


CONTROL    OF    THE    PATIENT.  337 

patient  in  the  manner  desired,  as  is  fully  possible  only 
in  special  institutions ;  but  this  apparent  disadvantage 
is  not  nearly  so  great  as  it  seems  at  first  glance,  for, 
as  a  rule,  the  general  practitioner  has  a  more  intelligent 
class  to  deal  with  than  the  institution  physician.  To 
the  latter,  patients  are  often  sent  only  after  their 
control  has  largely  been  lost  at  home. 

Barring  this  single  difference,  the  valuable  features 
of  treatment  now  so  greatly  in  vogue  in  colonies  of 
different  kinds  are  fully  as  valuable  to  the  epileptic 
treated  at  home  as  to  the  epileptic  whose  constant 
atmosphere  is  some  form  of  colony  life. 

The  Control  of  the  Patient  most  Essential. — We  may 
start  with  the  following  proposition,  applicable  without 
exception  to  every  case  alike:  The  more  absolutely  the 
physician  is  permitted  to  control  the  patient  in  every 
respect,  the  more  promising  the  hope  of  amelioration  or 
cure. 

This  may  be  accomplished  in  one  of  three  ways, 
depending  largely  upon  the  age,  general  intelligence, 
and  character  of  the  patient.  It  may  be  accom- 
plished first  by  securing  the  aid  of  the  patient  himself, 
having  him  fully  understand  what  he  must  do  in 
order  to  get  well,  and  at  the  same  time  show  a  perfect 
willingness  in  literally  carrying  out  every  direction 
imposed  upon  him.  Such  patients  will  be  quite  fre- 
quently encountered,  though  they  do  not  constitute 
the  majority,  for  the  reasons  that  epilepsy  being 
essentially  a  disease  of  early  life  and  so  often  causing 
mental  impairment  in  a  few  years'  time,  the  patient 
lacks  the  judgment  and  discretion  of  maturer  years, 
and  mental  faculties  unclouded  by  disease. 

But  there  still  remains  a  very  considerable  number 
whose  disease  does  not  appear  until  after  puberty, 
whose  general  development  and  education  up  to  that 
time  were  good,  and  whose  attacks  are  of  a  type  to 
permit  the  retention  of  a  comparatively  sound  mind, 


338  THE    GENERAL    TREATMENT    OF    EPILEPSY. 

good  judgment,  and  an  ambition  to  employ  e very- 
effort  to  recover.  It  is  in  such  cases  as  these  that 
the  physician  will  receive  the  patient's  full  aid,  always 
,  a  factor  of  prime  importance  in  the  attainment  of  the 
best  results. 

In  other  cases,  especially  children,  and  those  who 
bear  marked  evidences  of  the  effects  of  their  disease, 
such  as  mental  enfeeblement,  impaired  will  power, 
deficient  judgment,  incapacity  for  reasoning,  and 
moral  depravity  of  various  kinds;  who  have  no  voca- 
tion and  little  or  no  education ;  who  have  no  power  of 
applying  themselves  for  the  accomplishment  of  any 
definite  purpose — these  constitute  the  most  difficult 
class  to  handle  with  success,  and  it  can  be  done  only 
by  placing  the  patient  under  an  environment,  even 
without  his  full  acquiescence,  where  his  habits  will 
be  regulated  to  the  uttermost  detail. 

In  many  cases  the  family  can  give  the  attention 
required,  though  oftentimes,  especially  if  there  are 
other  children  in  the  family,  the  patient  is  a  constant 
source  of  solicitude  and  anxiety.  Irrespective  of  the 
influence  of  the  invalid  child  on  its  immediate  asso- 
ciates in  other  ways  not  desirable,  the  danger  from 
assault  by  the  patient  is  sometimes  great,  making  him 
a  constant  and  positive  menace  in  the  home.  This, 
to  be  sure,  is  not  always  the  case,  but  it  often  is ;  and 
when  we  recall  the  essentially  explosive  nature  of  the 
disease,  we  can  understand  the  risk  every  home 
assumes  in  keeping  an  epileptic  among  its  members. 

Another  factor  that  operates  strongly  against  the 
advisability  of  treating  some  epileptic  patients  in  their 
homes,  is  the  unavoidable  substitution  of  parental 
sympathy  for  the  necessary  degree  of  mild,  yet  whole- 
some discipline  that  most  epileptics  stand  so  greatly 
in  need  of.  They  do  not  require  this  discipline  so 
much  because  they  are  inherently  headstrong,  de- 
praved, or  incorrigible,  but  because  their  affliction  ever 


COLONY    LIFE.  339 

tends  to  give  them  a  degree  of  temperamental  ob- 
liquity of  an  unhappy  kind  that  comes  and  goes  most 
noticeably  along  with  the  seizure  periods,  which  is 
often  constantly  present  during  the  inter-paroxysmal 
period,  and  which  is  unquestionably  improved  under 
the  influence  of  self-restraint  when  such  influence  is 
forced  through  proper  disciplinary  measures  to  act. 

Teaching  the  epileptic  the  power  of  self-control  is 
one  of  the  most  valuable  things  we  can  put  in  his 
possession.  In  some  epileptics  the  exercise  of  inhibi- 
tion alone  may  prevent  the  occurrence  of  a  threatened 
attack. 

While  the  home  care  of  the  epileptic — his  supervision 
by  a  member  of  the  family — can  at  times  be  carried 
out  successfully,  by  far  the  most  satisfactory  plan 
outside  of  special  institutions  is  to  place  him  under 
the  care  of  a  nurse  or  attendant  especially  trained  in 
the  care  of  such  cases.  Only  under  this  condition  can 
the  patient  remain  in  his  own  home  to  the  best  ad- 
vantage. 

Colony  Life. — The  final  and  most  satisfactory  plan 
of  securing  full  control  of  the  patient  is  to  place  him 
in  a  colony  designed  for  all  types,  except  the  insane, 
or  in  one  for  selected  cases  only. 

Bethel  Colony  at  Bielefeld  in  the  province  of  West- 
phalia, Germany,  and  the  Craig  Colony  at  Sonyea  in 
Livingston  County,  New  York,  furnish  the  best  exam- 
ples of  general  colonies  at  this  time ;  while  the  smaller 
colony  at  Chalfont  St.  Peter,  near  London,  is  an 
example  of  those  for  selected  cases  only.  The  Craig 
Colony  admits  all  epileptics  except  the  insane,  receiv- 
ing on  this  basis  from  85  per  cent,  to  90  per  cent,  of 
all  who  apply.  Chalfont  St.  Peter  rejects  60  per  cent, 
as  undesirable,  either  because  of  their  unfavorable 
mental  condition  or  of  their  inability  to  become  useful 
factors  in  colony  life  (Turner). 

Both  types  of  colonies  have  particular  spheres  of 


34-0  THE    GENERAL    TREATMENT    OF    EPILEPSY. 

usefulness,  the  larger  and  more  cosmopolitan  of  the 
two  being  in  greater  favor  under  state  or  governmental 
supervision;  the  smaller,  best  suited  to  private  or 
semi-private  philanthropic  ends. 

The  principles  of  colony  life  in  either  case  are  the 
same.  It  would  be  interesting  in  this  connection  to 
briefly  review  the  history  of  the  colony  movement  from 
its  inception  in  France  in  1849  up  to  this  time,  but 
for  full  information  on  the  subject  the  reader  is  referred 
to  the  writings  mentioned  below.* 

We  outline  the  purposes  and  advantages  of  colonies 
as  follows : 

1.  They  provide  home  life,  simple  and  elemental  in 
form,  for  they  take  the  individual  from  his  own  home, 
unsuited  to  his  peculiar  needs,  to  homes  especially 
designed  to  supply  such  needs. 

2.  They  tend  to  preserve  individuality,  the  one 
thing  institutions  are  most  apt  to  destroy.  In  colo- 
nies, individuals,  not  units  and  numbers,  are  integral, 
essential  parts  of  the  whole. 

3 .  They  provide  vocations  for  all  who  require  them — 
vocations  ranging  from  the  simplest  to  the  most  com- 
plex, from  weeding  the  cabbage-patch  to  the  making 
of  brick  and  the  construction  of  houses;  they  provide 
education  that  begins  at  the  alphabet  and  ends  in 
some  profession  which  guarantees  self-support;  they 
provide  amusements  and  recreations  not  bound  by 
rules  of  necessity,  regularity,  and  formality ;  they  pro- 
vide for  the  organization  of  homes  in  a  way  to  throw 
congenial  spirits  into  pleasant  companionship,  and  to 
place  the  less  fortunate,  the  less  desirable,  in  a  class 
apart.     Ideal  colonies  provide,  in  short,   for  the  in- 

*  "Bethel  Colony  at  Bielefeld,  Germany,"  by  F.  Peterson,  "Medical 
Record,"  188.7.  "A  Colony  of  Mercy,"  by  Julie  Sutter.  "The  Care  and 
Treatment  of  Epileptics,"  by  Hon.  William  P.  Letchworth,  LL.D.,  1900. 
"Report  of  the  Proceedings  of  the  Annual  Meeting  of  the  National  Asso- 
ciation for  the  Study  of  Epilepsy,"  1901.  "Institutions  for  Epileptics," 
by  the  author,  "Journal  Amer.  Med.  Association,"  1902. 


COLONY   LIFE.  341 

finity  of  simple,  daily,  homely  necessities  that  go  to 
create  and  keep  cemented  together  the  best  features 
of  communal  life.  In  doing  this  they  are  more  than 
homes  in  that  they  provide  the  highest  treatment  for 
disease,  training  along  all  lines,  encouragement  wher- 
ever required,  upbuilding  of  character,  and  the  neces- 
sary healthful  restraint  for  all  who  need  it;  and  they 
are  less  than  institutions  in  that  they  do  not  destroy 
the  individuality  that  counts  for  more  than  all  the 
rest,  but  singles  it  out  and  bases  all  help  upon  its 
character. 

The  epileptic,  the  chronic  insane,  and  the  feeble- 
minded can  all  be  successfully  colonized.  The  system 
is  not  one  of  rigid  requirements  in  little  ways ;  it  may 
suitably  be  modified  to  meet  the  peculiar  needs  of  the 
three  classes  named.  But  in  the  care  of  all  classes 
its  fundamental  features  are  the  same.  To  modify 
these  would  be  fatal  to  the  system  itself. 

The  chronic  insane  and  the  feeble-minded  can  be 
cared  for  in  other  ways,  in  a  few  buildings,  or,  what  is 
less  desirable,  in  a  single  large  building;  but  epileptics 
cannot  be  cared  for  successfully,  or  even  with  partial 
success,  in  any  other  way  than  under  the  colony  plan. 
For  the  epileptic  it  is  ideal ;  for  the  insane  and  feeble- 
minded it  would  be  a  long  step  in  advance  of  methods 
now  in  use,  and  would  ultimately  prove  as  valuable 
as  it  has  for  the  epileptic. 

The  site  of  the  colony  should  be  removed  a  reason- 
able distance  from  centers  of  population.  The  de- 
fectives who  live  in  them  have  no  place  in  the  strenuous 
life.  They  are  infinitely  better  off  in  localities  where 
the  hum  and  roar,  the  wear  and  tear  and  strain  put 
upon  the  strong  in  the  outside  world  do  not  penetrate. 
They  also  require  seclusion  from  the  things  that  lead  to 
dissipation, — things  that  everywhere  abound  in  city 
life,  but  find  their  lowest  ebb  in  rural  communities. 

The  colony  estate  should  be  large — fully  an  acre  to 
each  individual. 


342  THE    GENERAL    TREATMENT    OF    EPILEPSY. 

Colonists  should  attend  schools  and  acquire  trades. 
At  Sonyea  they  are  graded  into  classes,  with  teachers 
for  each  class.  The  boys  attend  the  Sloyd  School, 
which  fits  them  in  two  or  three  years  to  take  up 
advanced  carpentry.  They  build  houses  and  make 
furniture.  Others  are  apprenticed  to  the  painter,  the 
upholsterer,  the  printer,  the  blacksmith,  the  mason, 
the  engineer,  the  laundryman,  and  other  artisans;  all 
becoming  in  time  proficient  in  their  several  fields. 
They  have  short  hours  of  labor  and  are  led,  not  driven, 
to  work.  The}'  have  plenty  of  time  for  amusement 
and  recreation,  indulging  in  baseball,  football,  indoor 
games  of  all  kinds,  reading,  getting  up  stage  plays, 
and  spending  their  time  when  free  from  duty7  as  they 
desire,  or  as  people  in  ordinary  communities  do. 

Just  here  comes  in  the  most  valuable  part  of  it  all. 
All  are  free;  that  is,  all  who  have  enough  mind  to 
permit  them  to  exercise  self-care  to  a  safe  extent. 
There  are  no  barred  windows  or  locked  doors,  save 
for  the  few  whose  safety  demands  it;  and  yet  under 
this  liberal  system  less  than  one  per  cent,  leave  the 
colony  without  permission.  This  is  the  finest  feature 
of  the  entire  scheme,  the  feature  of  perfect  freedom. 
There  is  some  trouble,  to  be  sure,  for  we  are  dealing 
with  human  nature  diseased,  human  nature  patholog- 
ically modified,  which  makes  illogic  conduct  easy,  even 
necessary,  because  it  is  unavoidable.  Tt  is  my  con- 
viction that  many  institutions  would  do  greater  good 
if  they  would  adopt  measures  of  greater  freedom 
toward  those  they  care  for.  Witness  the  benefits 
derived  from  the  abolition  of  forms  of  bodily  restraint 
applied  to  the  insane,  and  forms  of  restraint  in  the 
way  of  walls  and  high  fences  about  hospital  buildings 
for  the  insane  during  the  past  quarter  of  a  century. 
A  notable  revolution  in  this  respect  has  been  at  work 
since  Pinel  struck  the  manacles  from  the  hands  of 
the  insane  at  the  old  Salpetriere  more  than  a  hundred 


COLONY    LIFE.  343 

years  ago,  when  he  said,  "I  am  convinced  that  these 
lunatics  are  so  unmanageable  only  because  they  are 
robbed  of  air  and  liberty,  and  I  dare  to  hope  much 
from  the  opposite  means  of  treatment." 

From  a  knowledge  acquired  through  experience  in 
an  institution  where  home  life  was  impossible,  and 
from  a  knowledge  of  the  home  life  prevailing  at  the 
Craig  Colony,  I  have  come  to  believe  that  the  home 
instinct  is  the  last  of  the  natural  desires  to  die  even 
in  a  people  who  suffer  mental  enfeeblement  through 
chronic  and  far-reaching  diseases. 

It  may  be  claimed  that  the  cost  of  building  cottages 
or  small  houses  is  greater  than  for  one  building  accom- 
modating hundreds,  but  this  opinion  is  erroneous.  It 
has  not  been  the  case  at  Sonyea. 

The  model  colony,  in  recognition  of  the  peculiar 
needs  of  epileptics,  will  provide  for  three  classes  of 
dwellings,  not  including  a  hospital,  as  follows : 

Class  I. — Houses  in  this  class  should  hold  anywhere 
from  twelve  to  eighteen  patients,  and  these  patients 
should  be  of  the  best;  good  enough  in  every  respect 
to  assume  the  entire  care  of  the  household  in  all  its 
details,  under  the  general  supervision  of  one  nurse  or 
employe,  who  should  look  after  sick  patients  and  make 
observations  of  the  seizures  for  the  physicians  in 
charge.  These  small  cottages  should  be  as  home-like, 
cozy,  and  attractive  as  possible,  and  no  room  should 
hold  more  than  two  persons,  while  half  of  the  patients 
should  have  single  rooms.  Approximately  20  per 
cent,  of  all  in  the  colony  will  live  in  houses  of  this  kind. 

Class  II. — Houses  in  this  class  should  be  large 
enough  to  accommodate  from  twenty-five  to  thirty- 
five  persons.  These  dwellings  need  to  be  more  numer- 
ous, for  in  them  the  great  middle  class,  numbering 
from  60  to  70  per  cent,  of  the  entire  population, 
will  find  a  home.  They  should  have  light  and  airy 
rooms,  large  hat  and  coat  rooms,  smoking  and  sitting 


344         THE    GENERAL    TREATMENT    OF    EPILEPSY. 

rooms  for  men,  and  plenty  of  closet  and  shelf  space — 
for  most  of  these  people  find  comfort  in  looking  after 
their  individual  possessions — ample  verandas,  reading 
and  writing  rooms.  To  lessen  the  danger  from  fire, 
they  should  not  be  grouped  closer  together  than  from 
seventy-five  to  one  hundred  feet,  nor  more  than  from 
ioo  to  150  feet  apart,  in  order  that  they  may  be 
heated  from  one  central  point,  and  that  all  the  patients 
of  a  group  may  use  one  shower  or  rain  bath,  there 
being  several  groups  in  all.  Some  houses  need  indi- 
vidual bathtubs  for  sick  or  feeble  persons;  but  great 
economy  of  time  will  be  gained  if  central  bathing  and 
heating  plants  are  established. 

Class  III. — This  class  should  consist  of  infirmaries — 
buildings  combining  home  and  hospital — for  the  use  of 
perpetually  bed-ridden,  paralytic,  or  other  helpless 
cases.  These  houses  should  be  large  enough  to  care 
for  from  10  per  cent,  to  20  per  cent,  of  the  epileptic 
colony,  and  one  such  structure  should  be  provided 
for  each  sex.  Each  building  should  contain  isolation 
rooms  for  cases  mentally  disturbed,  a  feature  common 
to  many  epileptics. 

In  addition  to  homes  for  patients,  colonies  should 
have  the  following  buildings: 

1.  A  house  for  administrative  work,  containing  no 
patients,  to  be  regulated  in  size  by  the  ultimate  size 
of  the  colony. 

2.  A  hospital  building,  complete  in  equipment  and 
thoroughly  modern  in  every  respect,  for  the  treatment 
of  acute  medical  and  surgical  cases. 

3.  Industrial  buildings,  including  laundry,  power 
plants,  and  bakery,  shops  for  new  and  repair  work 
in  wood,  iron,  printing,  upholstery,  leather,  plumbing, 
painting,  electric  and  steam  engineering,  tailoring, 
shoemaking,  and  dressmaking. 

4.  Special  industrial  buildings  for  educational  pur- 
poses; those  for  men  to  include  Sloyd  School,  trades 


MEDICO-PEDAGOGIC    TREATMENT.  345 

school,  carpenter  shop,  and  nearly  all  the  above  to  be 
used  in  an  elementary  way  by  apprentices  to  fit  them 
for  higher  and  more  practical  work  along  similar  lines. 
For  the  women,  laundering,  sewing,  knitting  by  hand 
and  machine,  darning,  rug-weaving,  basket-making, 
and  the  domestic  arts  should  be  engaged  in.  A  labora- 
tory for  scientific  research  is  an  important  feature. 

This  brief  exposition  of  the  colony  system  shows  the 
broad  principles  under  which  the  epileptic  should  live. 
For  obvious  reasons  all  cannot  take  advantage  of  it. 
At  the  same  time,  there  is  no  reason  why  the  individual 
patient  under  the  general  practitioner's  care  should 
not  have  colony  methods  pointed  out  to  him  in  a 
way  that,  if  persistently  followed,  will  be  very  sure  to 
materially  accrue  to  his  benefit. 

The  idea  of  invalidism  should  not  under  any  plan  of 
treatment  be  allowed  to  take  root  in  the  epileptic's 
mind,  but  should  be  constantly  combatted.  He  should 
not  be  made  to  feel  that  he  is  in  a  class  apart — unlike 
other  persons.  Such  conceptions  will  be  naturally 
forced  upon  him  fast  enough  through  his  being  denied 
the  privileges  of  the  public  schools,  attendance  at 
church,  public  exercises  of  all  kinds,  and  even  exclusion 
from  the  family  table. 

His  expulsion  from  the  common  life  augments  his 
morbid  temperament,  his  irritability,  his  inability  to 
express  his  thoughts,  his  moping,  his  apathy,  his 
natural  tendency  to  a  lack  of  sociability,  all  of  which 
tend  to  aid  in  his  often  being  reared  in  deplorable 
ignorance.  Neither  should  he  be  forced  forward  in  a 
way  that  makes  him  conspicuous  and  subjects  him  to 
unpleasant  comment  and  ridicule.  The  epileptic  child 
has  often  to  bear  the  latter  from  its  playmates.  Some 
feel  the  sting  of  it,  others  do  not.  Those  who  do  should 
be  given  protection  from  it,  for  it  may  do  lasting  injury 
in  cases  of  sensitive  disposition. 

The  medico-pedagogic  treatment  of  the  epileptic  is 


346  THE    GENERAL    TREATMENT    OF    EPILEPSY. 

essential  for  many  reasons,  the  chief  among  them 
being  that  it  is  more  than  educational — it  exercises 
a  curative  power  of  well-determined  distinction  in 
selected  cases. 

The  first  question  is  that  of  determining  the  form 
of  education  best  suited  to  the  individual  case,  and  the 
extent  to  which  it  should  be  carried. 

As  previously  stated,  the  cases  of  essential  epilepsy 
of  any  considerable  duration  are  comparatively  few  in 
which  there  is  not  some  mental  impairment.  This 
must  be  the  case  in  any  disease  that  so  injuriously 
affects  the  brain. 

The  epileptic  is  subject  to  marked  variations  in  his 
capacity  to  learn.  In  any  aggregation  of  epileptic 
school-children  there  will  almost  certainly  be  some 
whose  powers  of  comprehension  are  periodically  in- 
active and  sluggish  in  the  extreme,  and  at  times 
suspended  altogether,  to  be  restored  to  normal  activity 
after  the  effects  of  the  impending  attack  that  forced  the 
inertia  have  subsided. 

The  peculiarity  of  this  alternating  state  of  the  per- 
ceptive powers  shows  the  necessity  not  only  for  indi- 
vidual as  distinguished  from  group  or  class  instruction, 
but  for  constant  repetition  in  many  cases  of  the  matters 
taught. 

The  epileptic  must  be  taught  largely  under  a  system 
of  reiteration  pursued  with  the  greatest  patience.  We 
must  be  satisfied  in  many  cases  with  a  minimum  of 
result  under  a  maximum  of  effort.  In  some  cases  the 
seizure  appears  to  completely  and  instantly  destroy  the 
memory  of  a  thing  learned  but  a  short  while  before. 
This  shows  in  a  measure  the  degree  of  disorganization 
that  occurs  in  the  central  nervous  system  as  the  result 
of  the  seizure.  In  cases  of  epileptic  dementia  such 
destruction  is  carried  to  an  extreme  degree,  so  that  in 
suitable  cases  all  mental  power  may  be  effaced  per- 
manently and  completely  in  a  few  years'  time.     In 


MEDICO-PEDAGOGIC   TREATMENT.  347 

other  cases  in  which  the  attacks  are  more  motor  than 
psychic,  the  mind  may  suffer  almost  no  impairment 
under  frequently  repeated  attacks  of  many  years' 
duration.  The  recognition  of  this  point  aids  us  in 
selecting  patients  most  likely  to  learn  under  any 
system  of  instruction  as  distinguished  from  those  who 
will  be  least  likely  to  do  so,  or  who,  having  acquired 
some  knowledge,  will  be  most  apt  to  suffer  its  loss 
in  a  comparatively  short  while. 

The  very  fact  that  epilepsy  may  affect,  in  greater 
part  at  least,  a  single  faculty  or  part  of  the  body, 
should  be  sufficient  for  making  it  appear  that,  in  order 
to  base  a  system  of  education  for  the  epileptic  upon 
correct  physiologic  principles,  we  must  plan  it  along 
many  lines.  We  cannot  single  out  any  particular 
faculty  and  cultivate  it  to  the  exclusion  of  others. 
Education  must  be  neither  wholly  intellectual  nor 
wholly  physical,  but  a  definite  combination  of  the  two 
in  a  way  that  enhances  the  value  of  each.  The  neces- 
sity for  doing  this  is  further  augmented  when  we 
remember  that  the  type  of  the  disease  in  certain  cases 
(being  such  at  one  time  as  to  warrant  the  development 
of  certain  faculties)  may  later  change  so  as  to  affect, 
perhaps  destroy,  the  very  faculties  to  which  we  have 
paid  so  much  attention.  As  a  rule,  this  is  not  to  be 
feared,  but  its  possibility  must  not  be  forgotten. 

Without  laying  it  down  as  a  fact  applicable  in  all 
cases  alike,  it  is  generally  better  to  educate  the  epileptic 
in  a  physical  or  manual  way  than  in  a  way  purely 
intellectual. 

This  statement  is  based  on  the  carefully  observed 
results  from  the  two  systems  of  education  in  vogue  at 
the  Craig  Colony  among  from  80  to  100  younger 
epileptics  during  a  period  of  eight  years.  Most  of 
these,  it  should  be  noted,  were  partially  or  wholly 
dependent,  thus  requiring  a  form  of  education  valuable 
for  economic  and  therapeutic  reasons  combined,  the 
latter  being  the  main  object  always  in  view. 


348  THE    GENERAL    TREATMENT    OF    EPILEPSY. 

Wholly  outside  any  economic  considerations  what- 
ever, physical  education  for  all  classes  of  epileptics, 
no  matter  what  their  pecuniary  or  social  status  may 
be,  is,  for  reasons  purely  physiologic,  the  best  for  them 
in  ever}'  respect.  Manual  training  directed  along 
proper  lines  is  intellectual  also.  It  confers  upon  the 
muscular  system  a  practical  knowledge  ready  for  use 
at  a  moment's  call,  and  which  is  not  dissipated  or 
destroyed  by  a  single  or  by  repeated  seizures,  as  often 
happens  when  knowledge  is  intellectual  only. 

Take,  for  instance,  the  value  of  the  Sloyd  system 
of  education  *  in  this  respect.  Its  purpose  is  com- 
plexly educational,  as  may  be  seen  by  the  following : 

1.  It  requires  the  student  to  make  a  drawing  in 
detail  of  the  object  he  aims  to  produce,  whether  it  is 
a  simple  wedge,  a  penholder,  a  saw-handle,  a  cabinet 
of  drawers,  or  a  piece  of  carving.  To  do  this  he  must 
learn  to  use  with  precision  the  delicate  instruments 
needed  for  the  purpose.  This  cultivates  his  power  of 
muscular  sense  and  coordination,  the  very  thing  the 
established  epileptic  requires,  since  disorders  of  mo- 
tility, muscular  inefficiency,  and  inexactness  of  effort 
are  not  uncommon  results  of  the  disease. 

2 .  It  trains  the  mind  and  eye  in  the  habit  of  attentive 
observation.  Epileptics  are  especially  prone  to  show 
a  lack  of  concentration  of  effort,  a  very  notable  diffi- 
culty in  fixing  their  attention  continuously  upon  one 
thing  (aprosexia),  which  makes  it  necessary  to  drill 
them  assiduously  in  order  to  enable  them  to  carry  a 
given  task  to  its  completion. 

3.  It  encourages  the  faculty  of  thinking  largely 
through  the  mathematical  requirements  of  every  piece 
of  work  executed,  because  of  the  complete  diagram 
which  must,  first  be  made  of  it.  giving  its  dimensions 
to  a  scale. 

*  As  defined  by  an  American  authority:  "Sloyd  is  tool-work  so  arranged 
and  employed  as  to  stimulate  and  promote  vigorous,  intelligent  self-activity 
for  a  purpose  which  the  worker  recognizes  as  good." 


MEDICO-PEDAGOGIC   TREATMENT.  349 

4.  Finally,  when  the  image  of  the  full  requirement 
is  definitely  fixed  in  the  student's  mind,  he  must 
create  in  wood,  metal,  plaster,  clay,  leather,  or  what 
not,  the  object  itself;  so  taking  the  whole  process  into 
consideration  we  can  readily  understand  that  its 
educational  value  for  the  average  epileptic  is  very 
great. 

While  it  is  usually  taught  such  persons  only  in  the 
schoolsTof  special  institutions,  it  can  be  taken  up  by 
the  individual  patient  in  his  home  as  well.  If  he 
possesses  any  mechanical  faculty  whatever,  he  may 
successfully  carry  out  the  system  alone. 

The  mentally  feeble  child,  to  which  class  many  epi- 
leptics belong,  is  especially  incapable  of  comprehend- 
ing abstractions.  All  instruction,  therefore,  must  be 
presented  in  a  concrete  form  which  will  enable  it 
not  only  to  see,  but,  when  possible,  to  grasp  in  the 
hand  as  well  as  in  the  mind.  Many  of  the  games  and 
occupations  of  the  kindergarten  are  consequently  of 
service;  but  while  the  normal  child  exercises  its  own 
spontaneous  activity  through  these  occupations,  those 
who  are  mentally  deficient  in  an  apathetic  way  have 
to  be  stimulated  to  action  by  the  force  of  imitation. 

Our  system  of  education,  then,  starts  on  physiologic 
lines,  first  addressing  itself  to  the  culture  of  the  external 
senses,  then  to  the  coordination  of  muscular  movement, 
and  finally  to  the  promotion,  through  proper  exercises, 
both  of  the  manual  and  mental  activities  (Shuttle- 
worth)  . 

The  supreme  object  in  these  cases  is  to  substitute, 
if  possible,  the  purposeless,  irregular  movements 
with  those  of  a  definite  purpose.  In  this  way  only  can 
the  inability  to  fix  the  attention  be  overcome.  In 
undeveloped  epileptic  children  in  whom  nervous 
irritability  is  so  great  as  to  give  rise  to  destructive 
tendencies,  the  irregular,  purposeless,  illegitimate 
expenditure  of  energy  should  be  turned  into  construe-  | 


35°  THE    GENERAL    TREATMENT    OF    EPILEPSY. 

tive  channels.  Children  of  this  type  may  be  gently 
coaxed  into  building  something  of  definite  form  with 
blocks  for  the  simple  pleasure  of  destroying  it  later. 

Other  simple  educational  implements  and  means  for 
the  very  backward  may  be  employed,  such  as  the  peg- 
board,  size-board,  form-board,  graduated  wooden  rods 
and  blocks,  domino-boards,  simple  exercises  in  mathe- 
matics, drawing,  reading,  and  writing;  also  object- 
lessons  that  frequently  bring  under  the  child's  notice 
all  the  simple  familiar  objects  of  daily  life  should  be 
employed  in  suitable  cases.* 

These  elemental  measures  apply  more  particularly 
to  the  epileptic  child  whose  disease  has  developed 
before  the  seventh  or  eighth  year.  More  advanced 
methods  are  called  for  in  children  who  have  had  some 
school  advantages  before  they  became  epileptic.  In 
these,  the  system  of  instruction  is  not  essentially 
different  from  that  followed  in  ordinary  schools, 
though  we  will  find  that  they  fall  far  short  of  making 
the  progress  of  the  ordinary  child.  Epileptic  students 
about  the  age  of  from  sixteen  to  twenty  generally 
show  the  mental  development  of  children  of  from  eight 
to  twelve  years. 

In  a  class  of  60  girls  at  the  Craig  Colony,  the  average 
age  of  those  in  the  first  (highest)  grade  was  nineteen 
years;  in  the  second,  sixteen  years  and  a  half;  in  the 
third,  fifteen  years  and  a  half.  With  one  or  two 
possible  exceptions,  none  of  these  could  reach  the 
standard  of  work  required  of  normal  children. 

Whatever  the  mental  status  or  age  of  the  epileptic 
student,  the  scope  of  his  instruction  should  be  broad 

*  Reference  works  on  educational  training:  Shuttleworth,  "Mentally 
Deficient  Children,"  1900;  Bourneville,  "Recherches  cliniques  et  thera- 
peutiques  sur  Fepilepsie,  Fhysterie  et  Fidiotie,"  "Report  Bicetre,"  1901; 
Froebel's  "Letters  on  the  Kindergarten,"  1901;  the  writings  of  Sequin, 
Dean,  Anna  Snell,  Gill,  and  reports  of  New  York,  Massachusetts,  Illinois, 
Pennsylvania,  and  other  State  institutions  for  educating  the  defective 
classes. 


OUTDOOR  AND  INDOOR  LIFE. 


351 


and  should  lean  to  the  cultivation   of   the   physical 
rather  than  to  the  purely  mental  side. 

Systematic  outdoor  life  requiring  a  modicum  of 
activity  is  better  than  any  form  of  sedentary  occupa- 
tion and  should  be  required  whenever  possible.  Ex- 
cessive physical  labor  that  causes  exhausting  fatigue 
is  no  more  advisable  than  severe  mental  labor  which 
for  the  epileptic  is  always  bad.  Such  occupations 
as  gardening,  seed-gathering,  farming,  wood-cutting, 
brick-making,  dairying,  herding  cows  and  sheep, 
ranch  life,  working  about  lawns,  grading,  cultivating 
flowers,  raising  chickens,  and  the  like,  are  all  admirable 
for  epileptics  who  show  or  can  be  induced  to  cultivate 
fondness  for  them. 

The  records  at  the  _Craig  Colony  show  that  attacks  I 
among  male  patients  are  noticeably  less  in  summer  ; 
when  outdoor  activity  is  possible  to  the  fullest  extent, 
than  in  winter  when  it  is  not. 

They  also  show  that  female  patients  do  not  experi- 
ence the  same  degree  of  improvement  that  male 
patients  do  because  of  the  sedentary  life  of  the  former. 

TABLE  SHOWING  COMPARATIVE  FREQUENCY  OF  ATTACKS 
IN   DIFFERENT   SEASONS    OF   THE    YEAR 
IN  THE  TWO   SEXES. 

Male. 

January 57x8 

February 532° 

March 6363 

July 4735 

August 4922 

September 4723 

Indoor  occupations  that  are  suitable  include  printing, 
painting,  shoemaking,  glazing,  carving,  modeling  in 
clay,  carpentry  in  all  its  branches,  upholstering, 
plumbing,  broom-,  brush-,  and  basket-making,  rug- 
and  carpet-weaving.  Under  supervision,  selected  pa- 
tients (as  at  Sonyea)  may  act  as  engineers,  firemen, 
masons'     assistants,     teamsters,     machinists,     book- 


Female. 

Total 

325° 

8968 

2929 

8249 

3258 

9621 

3439 

8174 

363S 

8557 

342  7 

8150 

352  THE    GENERAL    TREATMENT    OF    EPILEPSY. 

keepers,  seamstresses,  and  they  may  do  all  manner 
of  housework,  including  cooking.  Epileptics  should 
enjoy  as  much  recreation  as  possible.  They  may 
safely  play  tennis,  golf,  baseball,  football,  basket-ball, 
indulge  in  athletic  contests  of  almost  every  form, 
practice  in  the  gymnasium  (which  is  heartily  recom- 
mended under  proper  caution) ,  and  take  part  in  any  of 
the  indoor  amusements  common  to  other  people. 

Emotional  girls  and  young  women  are  better  for 
not  attending  the  drama  and  other  places  of  amuse- 
ment that  excite  the  emotions.  Attacks  may  be 
induced  in  this  way. 

Like  other  defectives,  epileptics  are  fond  of  music, 
and  its  influence  on  them  is  beneficial.  Stage  plays 
are  useful  in  cultivating  self-confidence  and  improving 
articulation. 

Smoking  by  the  young  epileptics  should  be  forbid- 
den. If  the  habit  is  not  contracted  until  after  adult 
life  and  moderately  indulged  in  (cigarettes  excluded), 
it  often  does  no  harm.  In  some  cases  we  have  known 
smoking  to  bring  a  calm  that  the  individual  stood  in 
need  of. 

Marriage. — The  physician  may  be  called  upon  to 
give  advice  on  this  point.  If  so,  his  position  will  be 
difficult.  He  can  best  answer  by  viewing  the  matter 
from  two  points:  (j)  That  of  the  probable  effect  it 
will  have  on  the  disease  itself  when  present  on  either 
side;  (2)  the  liability  of  its  transmission  to  the  off- 
spring. As  to  the  first,  he  may  say  that,  as  a  rule, 
no  good  accrues  to  the  individual,  so  far  as  the  dis- 
ease is  concerned,  from  the  assumption  of  the  married 
state ;  and  as  to  the  second,  that  the  marriage  of  epi- 
leptics puts  the  strongest  possible  premium  upon  the 
creation  of  epileptic  progeny.  There  are  rare  cases  in 
which  parents  contract  the  disease  comparatively  late 
in  life,  in  whom  it  may  not  for  some  time  be  the 
essential  malady,  and  whose  offspring  are  quite  sure 


diet.  353 

not  to  be  epileptic.     Such  instances,  however,  are  rare,  j 
and  require  the  most  delicate  selection  under  medical 
investigation. 

Assume  the  proper  attachment  between  man  and 
wife,  one  being  epileptic,  and  eliminate  the  possibility 
of  epileptic  offspring,  there  may  be  good  reasons  why 
marriage  in  such  cases  should  be  sanctioned.  But 
who  can  doubt  the  extreme  rarity  of  these  conditions  ? 
On  the  whole,  it  is  better  in  every  way  that  epileptics 
should  not  marry. 

Diet. — The  question  of  diet  is  one  of  great  impor- 
tance, though  not  of  the  same  value  in  all  cases.  Im- 
proved methods  of  administering  the  bromid  salts  of 
late  years  have  greatly  lessened  the  need  for  dietetic 
restrictions.  There  is  no  question  that  the  ill  effects 
of  the  bromids,  as  shown  in  part  by  the  manner  in 
which  under  injudicious  administration  they  impair 
digestion,  have  often  led  to  the  assumption  that  imper- 
fect diet  was  causing  or  aggravating  the  disease, 
whereas  the  blame  should  have  fallen  upon  the  drug 
itself  and  its  power  to  produce  gastro -intestinal  dis- 
orders. 

A  few  years  ago,  when  it  was  customary  to  receive 
patients  into  the  Colony,  to  whom  large  doses  of  the 
bromids  had  been  administered  for  years  without  regard 
to  the  possible  obviation  of  their  toxic  properties,  it 
was  noted  that  stomach  disorders  with  their  attendant 
results — anemia,  headaches,  loss  of  flesh,  insomnia, 
general  feebleness,  etc. — were  far  more  frequent  than 
later  on  when  the  bromids  were  more  rationally  used. 
The  diet  in  most  cases  had  later  been  corrected  also, 
but  even  under  the  same  diet  improved  ways  of  giving 
the  bromids  greatly  lessened  stomach  disorders. 

All   epileptics   do   not   demand   the   same   detailed 

dietetic   considerations,   although  the    principles    are 

essentially  the  same  in  all.     To  say  that  no  epileptic 

should  eat  meat  would  be  as  wrong  as  to  say  that  all 

23 


354         THE    GENERAL    TREATMENT    OF    EPILEPSY. 

should  eat  it.  I  have  been  unable  to  determine  that 
different  foods  have  any  specific  effect  on  epilepsy 
itself  beyond  that  which  .they  have  on  the  organism 
in  general,  the  state  of  which  influences  the  disease 
favorably  or  otherwise. 

The  epileptic  first  of  all  demands  a  sound,  vigorous 
body,  perfect  in  all  its  parts.  His  food  requirements 
are  greater  than  those  of  almost  any  other  class.  He 
is  justly  credited  with  having  a  voracious  appetite. 
The  reason  of  this  is  probably  found  in  the  necessity 
for  constantly  restoring  bodily  energy  that  through 
periodic  "nervous  discharges"  is  constantly  going  to 
waste.  That  he  should  eat  much  is  a  demand  founded 
on  the  results  of  his  disease. 

It  is  essential  that  he  be  properly  guided  in  his 
food  habits.  Oftentimes  more  can  be  done  for  him  in 
this  than  in  any  other  way,  especially  in  cases  in  which 
the  disease  is  autotoxic  in  origin  and  in  which  dietetic 
indiscretions  bring  on  a  seizure.  In  many  such  cases 
the  nutritional  balance— the  fine  line  that  separates 
physiologic  processes  in  nutrition  from  those  that  are 
pathologic — is  extremely  delicate,  requiring  time  and 
patience  and  repeated  trial  to  find  its  adjustment. 

Without  attempting  to  review  the  whole  process  of 
digestion,  the  following  practical  suggestions  from  a 
general  hygienic  and  therapeutic  point  of  view  are 
worthy  of  consideration. 

Assuming  first  that  the  patient  is  free  from  gastro- 
intestinal disorders  of  any  kind — constipation,  chronic 
diarrhea  or  dysentery,  indigestion,  flatulence,  or 
catarrh — he  can  best  be  kept  so,  or,  if  he  suffers  in  such 
ways,  be  largely  or  wholly  relieved  by  observing  the 
following  to  the  letter. 

i .  Regularity  in  eating  is  of  first  importance ;  irregu- 
larity tends  to  disease. 

2.  Moderation  in  the  quantity  eaten  should  be 
strictly  enjoined  in  every  case  in  which  there  is  a 


FOOD    ARTICLES    FOR    EPILEPTICS.  355 

tendency  to  overeat — a  fault  common  to  many  suf- 
ferers from  the  disease. 

3.  Food  should  never  be  taken  under  stress  of 
limited  time — every  morsel  of  it  should  be  thoroughly 
masticated  before  it  is  swallowed.  Epileptics  of 
inferior  grades  are  prone  to  bolt  their  food  almost 
wholly  unmasticated. 

To  formulate  a  practical  dietary  for  epileptics  it 
must  be  made  easy  and  inexpensive  of  preparation, 
for  it  will  be  required  daily  for  years.  It  must  con- 
tain a  proper  proportion  of  the  three  groups  of  food 
stuffs— albumin,  carbohydrates,  and  fats.  While 
vegetarians  (like  the  Hindoos)  live  and  thrive  prin- 
cipally on  non-nitrogenous  substances,  such  as  vege- 
tables and  fruits,  other  races  (like  the  Esquimos)  live 
almost  wholly  on  nitrogenous  articles,  but  history 
shows  that  the  highest  attainments  of  the  human 
race  have  emanated  from  those  who  have  lived  on  a 
mixed  diet  (Virchow). 

LIST  OF  FOOD  ARTICLES  SUITABLE  FOR  EPILEPTICS. 

FOR  BREAKFAST. 

Fruit. — Grapes ;  grape  fruit ;  oranges ;  apples,  peaches, 
pears,  cooked  or  raw,  as  usually  served; 
prunes. 

Cereals. — A  modicum  of  cereals  only  is  advised. 
While  they  are  nutritious,  used  to  excess 
they  tend  to  weaken  the  digestive  system. 
They  require  to  be  thoroughly  cooked, 
and  include  oatmeal,  cracked  wheat, 
hominy,  grits,  etc. 

Eggs. — These  are  of  especial  value  and  may  be  eaten 
in  almost  any  form,  except  fried, — soft 
boiled,  scrambled,  poached  on  toast, 
omelet  souffle.  According  to  the  manner 
in  which  they  are  prepared,  eggs  are 
digested    in    from    an    hour    and    three- 


356         THE    GENERAL    TREATMENT    OF    EPILEPSY. 

quarters  to  three  hours,  hard  boiled 
and  omelet  souffle  taking  the  longest 
time  (Penzoldt). 

Bread. — Ordinary  baker's  bread,  not  too  fresh; 
Graham,  gluten,  entire  wheat,  and  corn- 
bread  muffins.  Toast  in  any  form  is 
especially  good. 

Liquids. — Coffee,  tea,  milk,  cocoa,  chocolate.  A 
minimum  of  coffee  and  tea  is  advised. 
The  best  drink  is  milk.  It  contains  all 
the  elements  of  a  typical  diet,  including 
albuminous  substances  in  the  form  of 
casein  and  serum  albumin,  fats  in  cream, 
carbohydrate  in  the  form  of  lactose  or 
sugar  of  milk;  salts,  chiefly  of  lime,  and 
water.  It  is  easily  digested,  remaining 
in  the  stomach  but  little  longer  than  plain 
water,  which  makes  it  an  ideal  food. 
Coffee  and  tea  should  be  made  quite 
weak  and  lightly  sweetened. 

FOR    DINNER    (NOON). 

Oysters. — These  may  be  raw  or  cooked  any  way, 
except  fried. 

Soups. — Vegetable,  thoroughly  cooked ;  tomato,  plain ; 
tomato  bisque;  consomme;  pea;  potato; 
vegetable,  corn,  and  lamb  broth.  Mock 
turtle  and  other  rich  soups  should  be 
avoided. 

Meats. — Most  epileptics  can  eat  some  meat  not  only 
with  impunity,  but  with  benefit.  It 
should  be  a  part  of  the  noon  meal  only 
and  consist  either  of  lamb,  beef,  mutton, 
fowl  of  almost  any  kind,  or  baked  or 
broiled  fish.  The  quantity  of  meat  should 
be  small  in  either  case.  Fowl  or  game 
should  be  broiled,  roasted,  or  fricasseed, 


FOOD    ARTICLES    FOR    EPILEPTICS.  357 

never  fried.  Rich  sauces  should  be  ab- 
jured.    Simple  meat  juices  do  no  harm. 

Vegetables.- — Potatoes  white  or  sweet,  spinach,  carrots, 
parsnips,  onions,  lima  beans,  peas,  okra, 
squash,  string  beans,  asparagus,  egg-plant 
(broiled),  green  corn,  tomatoes,  and  tur- 
nips. Avoid  cucumbers  and  cabbage  in 
any  form.  All  vegetables  should  be  thor- 
oughly cooked. 

Relishes. — Olives,  radishes,  lettuce,  celery;  peanuts 
and  almonds,  plain  or  salted. 

Dessert. — This  should  always  be  simple  and  consist  of 
light  puddings,  such  as  bread,  farina, 
rice,  tapioca,  custard;  cheese  and  crackers. 
Pudding  sauces  should  be  plain  and  never 
contain  wine  or  alcohol  in  any  form. 

FOR    SUPPER. 

The  last  meal  of  the  day  should  be  eaten  not  less 
than  an  hour  and  a  half  or  two  hours  before  retiring. 
It  is  best  for  the  epileptic  to  retire  on  an  empty  stom- 
ach, so  this  should  be  the  lightest  meal  of  the  day, 
consisting  of  toast,  crackers,  bread  and  butter,  eggs 
in  any  of  the  forms  named  for  breakfast;  prunes, 
stewed  or  baked  apples,  pears,  weak  tea,  cocoa,  choco- 
late. Hot  corn  bread  and  boiled  hot  rice  two  or  three 
times  a  week,  if  desired. 

What  Not  to  Eat  or  Drink. 

Small  berries  with  hard  seeds,   such  as  blackberries 

and  raspberries. 
Cake  in  any  form. 
Pastry  in  any  form. 

Pork,  veal,  ham,  or  anything  fried  in  grease. 
All  alcoholic  drinks;    even  the  lightest  beer  should 

be  avoided. 


358         THE    GENERAL    TREATMENT    OF    EPILEPSY. 

The  principles  underlying  a  suitable  diet  for  epileptics 
are  simple.  They  embody  the  use  of  bread-stuffs, 
butter,  milk,  fruits,  cereals,  etc.,  to  the  exclusion  of  too 
much  meat,  pastry,  and  other  less  digestible  articles. 
The  above  diet  is  not  presented  as  final  for  adaptation 
in  toto  in  each  case,  but  under  trial  it  can  be  made  to 
suit  any  in  which  the  requirements  are  not  unusual. 


CHAPTER  XIV. 
THE  MEDICAL  TREATMENT  OF  EPILEPSY. 

Prevention  of  Attacks.  Treatment  of  Attacks.  Drugs:  The  Bromin 
Preparations.  Their  Physiologic  Action.  The  Prevention  of  Bromid  In- 
toxication. The  Hypochlorization  Method.  How  the  Bromids  Act.  The 
Opium-bromid  Treatment  of  Flechsig.  Codein.  Borax.  Nitroglycerin. 
Chloretone.  Zinc.  Sodium  Biborate.  Urethane.  Solanum  Carolinense. 
Simulo.  Chloral  Hydrate.  Amylene  Hydrate.  Belladonna.  The  Coal- 
tar  Derivatives.  Iron.  Chloroform.  Electricity.  The  Relief  of  Eye- 
strain. Serotherapy.  Hydrotherapy.  The  Influence  of  Concurrent 
Diseases. 

The  medical  treatment  of  any  disease  in  which  the 
etiology  and  pathology  are  as  obscure  as  they  are  in 
epilepsy  must  be  more  or  less  empirical. 

As  will  be  seen  later  on,  this  applies  even  to  the  use 
of  bromid  in  epilepsy,  a  drug  that  has  enjoyed  well- 
nigh  unusual  prestige  in  the  treatment  of  the  disease 
for  more  than  half  a  century. 

Other  forms  of  treatment  not  strictly  medical,  and 
yet  not  surgical,  are  reviewed  in  this  chapter. 

The  Prevention  of  an  Immediate  Attack. — When  an 
aura  precedes  the  attacks  a  sufficient  length  of  time, 
the  seizure  may  not  infrequently  be  prevented.  One 
method  is  by  inhalations  of  nitrite  of  amyl.  For  this 
purpose,  nitrite  of  amyl  pearls  are  carried  in  the  pocket 
and  one  is  broken  in  the  handkerchief  when  occasion 
arises ;  or  the  patient  keeps  with  him  a  small  vial  with 
ground-glass  stopper  containing  a  piece  of  cotton 
saturated  with  the  drug.  In  the  majority  of  cases, 
however,  the  patient  is  powerless  to  apply  any  remedy 
himself.  With  the  aura  there  usually  comes  confusion 
which  destroys  intelligent  action. 

It  is  assumed  that  the  nitrite  of  amyl  acts  beneficially 

359 


360  THE    MEDICAL    TREATMENT    OF    EPILEPSY. 

by  flooding  the  brain  with  arterial  blood,  a  potent 
agent  for  modifying  the  action  of  nerve  elements 
(Gowers). 

Attacks  can  sometimes  be  arrested  in  other  ways. 
When  they  begin  in  one  extremity,  they  may  be 
checked  by  tying  a  ligature  tightly  about  the  leg  or 
arm  involved.  It  has  been  advocated  for  such  patients 
that  they  wear  a  double  piece  of  tape  looped  about 
the  arm  above  the  elbow,  the  ends  hanging  down 
below  the  sleeve.  As  soon  as  the  fit  is  felt  coming, 
the  string  is  pulled  tight.  Xow  and  then  the  repeated 
arrest  of  fits  in  this  way  is  said  to  have  a  permanent 
effect. 

Faucher  recommends  hypodermic  injections  of  -^ 
to  y^  of  a  grain  of  apomorphin  as  a  speedy  means  of 
arresting  an  attack.  I  have  found  it  effective  in  some 
cases. 

Brown-Sequard  and  Buzzard  tried  to  permanently 
abort  attacks  by  keeping  a  blister  about  the  limb. 

As  a  rule,  however,  little  or  nothing  is  gained  by 
checking  an  approaching  attack.  It  may  be  advisable 
at  times  on  account  of  the  patient's  environment  to 
do  so,  but  when  checked,  later  attacks  seem  more 
severe,  thus  evidencing  a  cumulative  action. 

Several  male  patients  under  the  writer's  care  banded 
together  to  prevent  attacks  in  one  another  by  rubbing 
and  slapping  the  side  of  the  face  and  neck  of  the 
victim  threatened  with  the  seizure.  The  plan  was  not 
infrequently  effective  for  weeks  at  a  time  in  some  of 
them,  though  I  cannot  say  that  any  permanent  benefit 
came  from  it.* 

*  I  ago.     My  lord  is  fallen  into  an  epilepsy: 

This  is  his  second  fit;  he  had  one  yesterday. 
Cas.      Rub  him  about  the  temples: 

No,  forbear; 
Iago.     The  lethargy  must  have  his  quiet  course; 
If  not,  he  foams  at  mouth,  and  by  and  by, 
Breaks  out  to  savage  madness. 

"Othello,"  Act  iv. 


TREATMENT    DURING    ATTACK.  36 1 

I  have  previously  called  attention  ("Albany  Medical 
Annals,"  Vol.  liii)  to  the  value  of  an  occasional  con- 
vulsion in  certain  cases.  In  some  patients  the  fit  acts 
as  a  safety  valve  that  unquestionably  permits  escape 
from  insanity.  I  referred  to  the  matter  in  part  as  fol- 
lows: "  In  many  cases  the  convulsion  seems  to  come  as 
the  termination  of  an  obscure  autotoxic  cycle  which 
varies  in  duration  in  different  individuals  and  bears 
some  relationship  to  the  ascending  period  of  the  folie 
circulaire  of  the  French.  It  seems  that  the  specific 
cause  of  the  fit  in  these  cases  is  something  that  per- 
meates the  entire  organism ;  something  that  comes  and 
goes;  that  grows  rapidly  in  intensity,  exerting  a  per- 
nicious influence  on  the  patient  by  making  him  act 
out  of  harmony  with  his  normal  state,  until  the  limit 
is  reached  and  the  mind  loses  its  direction  and  control. 
The  power  of  inhibition  being  finally  destroyed,  the 
nervous  storm  breaks  with  great  force  and  violence,  the 
systemic  poison  is  neutralized  or  destroyed,  equilibrium  \ 
is  restored,  and  all  is  quiet  and  serene  once  more." 

Alcoholics  constitute  a  second  class,  in  whom  a  con- 
vulsion or  two  may  have  a  salutary  effect  in  causing 
them  to  quit  drinking. 

Treatment  During  an  Attack. — During  an  attack 
little  treatment  is  necessary.  Constricting  clothing 
about  the  neck  should  be  loosened  to  lessen  the  danger 
of  hemorrhagic  extravasation  into  the  skin  of  the  face, 
neck,  and  conjunctivae. 

When  vomiting  threatens  just  after  the  attack,  the 
patient  should  be  placed  on  the  side  to  lessen  the 
danger  of  vomited  substances  falling  back  into  the 
larynx.  This  is  rarely  a  cause  of  death — one  that  I 
have  never  seen.  Gowers  mentions  a  single  case  of 
the  kind. 

If  the  attacks  occur  at  night,  there  is  danger  to 
life  from  suffocation.  In  observations  I  made  in  ioo 
nocturnal  epileptics,  it  was  found  that  13  per  cent,  of 


362  THE    MEDICAL    TREATMENT    OF    EPILEPSY. 

them  were  turned  on  their  faces  by  the  force  of  the 
convulsion.  Many  would  have  suffocated  had  they 
not  been  relieved  from  the  position.  The  friends  of 
the  patient  should  always  be  warned  of  this  danger. 

The  sleep  that  so  frequently  follows  an  attack 
should  not  be  prevented.  If  it  is,  the  patient  suffers 
more  from  headache  and  is  longer  in  recovering  from 
the  effects  of  the  attack.  The  prostration  that  so 
often  follows  rarely  calls  for  treatment.  It  will  pass 
away  naturally  in  time. 

For  obvious  reasons  the  patient  should  be  laid  down 
if  he  can  be  reached  in  time,  not  because  posture  in- 
fluences the  attack  one  way  or  another,  so  far  as  we 
know,  but  to  prevent  possible  injury  from  falling.  It 
is  possible  in  some  cases  to  prevent  the  tongue  being 
bitten  by  placing  a  piece  of  cork  or  India  rubber  be- 
tween the  teeth. 

DRUGS. 

Drugs  are  administered  in  epilepsy  for  the  purpose 
of  influencing  the  attacks,  either  by  arresting  their 
occurrence  or,  failing  in  this,  by  rendering  them  less 
frequent  and  less  severe. 

As  yet  we  are  ignorant  of  any  means  of  suddenly 
curing  the  disease,  and  from  what  we  now  know  of  its 
etiology  and  pathology,  it  seems  unlikely  that  any 
means  of  rapid  or  sudden  cure  will  be  forthcoming  in 
the  immediate  future.  This  pertains  to  true  epilepsy ; 
not  to  less  fundamental  convulsions,  some  of  which  are 
capable  of  early  eradication. 

Unfortunately  the  influence  of  drugs  is  transient, 
making  necessary  their  repeated  renewal.  The  only 
way  in  which  permanent  benefits  from  them  can  be 
obtained  is  to  persist  in  their  administration  for  years, 
while  some  epileptics  must  take  them  continuously. 
The  necessity  for  prolonged  treatment  should  be  made 
clear  to  the  patient  at  the  outset.     If  he  is  capable  of 


DRUGS.  363 

understanding  why  this  is  so,  it  should  be  explained  to 
him  in  order  that  his  co-operation  may  be  enlisted. 

The  Bromin  Preparations.— Since  their  introduction 
by  Laycock  half  a  century  ago,  the  salts  of  bromin 
have  enjoyed  steady  favor  as  anti-epileptic  remedies, 
notwithstanding  the  fact  that  they  fall  far  short  of 
meeting  the  important  indications.  Within  recent 
years  a  marked  improvement  has  been  made  in  the 
methods  of  their  administration,  simultaneously  les- 
sening the  evils  they  produce  and  enhancing  their 
power  for  good. 

Much  of  the  discredit  heaped  upon  the  drug  in  the 
past  has  been  due  to  the  unguarded  manner  of  its  use. 
Many  failures  to  cure  have  largely  been  due  to  the 
same  cause. 

Indefinite  suppression  of  epileptic  phenomena  must 
not  be  mistaken  for  cure.  All  drug  treatment  must 
be  combined  with  the  very  essential  general  treatment 
I  have  elsewhere  described.  We  must  not  feel  that  any 
one  remedy  can  suffice;  and  above  all,  that  we  have 
in  the  bromids  the  sum  and  essence  of  all  drug  treat- 
ment required. 

The  Physiologic  Action  of  the  Bromids. — The  action 
on  the  human  economy  of  all  the  bromid  salts  is 
essentially  the  same.  The  minor  differences  of  the 
various  preparations  worthy  of  note  in  the  treatment 
of  epilepsy  will  be  mentioned  later. 

On  the  nervous  system  the  bromid  of  potassium — 
the  remedy  universal — acts  as  a  distinct  motor  de- 
pressant, coincidently  lessening  the  activity  of  the 
intellectual  centers.  When  pushed  to  an  extreme  de- 
gree it  produces  apathy,  listlessness,  lack  of  interest  in 
surroundings,  a  dull  apathetic  expression,  and,  if 
carried  still  further,  produces  a  mental  condition  not 
unlike  that  of  primary  dementia  or  stuporous  melan- 
cholia— a  condition  from  which  the  patient  usually 
makes  a  good  recovery  when  the  drug  is  withdrawn. 


364  THE    MEDICAL    TREATMENT    OF    EPILEPSY. 

If  pushed  too  far,  death  may  supervene  from  acute 
bromid  poisoning.  This  happened  in  the  case  of  a  boy 
of  twelve  years  whom  I  knew,  whose  parents  gave 
him  too  frequent  doses  of  a  patent  nostrum,  the 
essential  ingredient  of  which  (as  with  the  bulk  of 
patent  epileptic  cures)  was  the  bromid  of  potassium. 

Bromid  also  exerts  a  sedative  action  on  the  spinal 
cord,  lessening  reflex  excitability  in  this  way. 

On  the  circulation  it  causes  at  first  a  fall  in  arterial 
pressure.  If  given  in  toxic  doses,  it  arrests  the  heart 
in  diastole,  while  its  long-continued  use  results  in  a 
weakened  and  irritable  condition  of  that  organ  and 
a  general  impairment  of  the  circulation,  causing  cold 
hands  and  feet  with  general  blueness  of  the  body. 

On  the  respiration,  in  ordinary  doses,  it  produces 
but  little  effect ;  in  larger  doses  it  acts  as  a  depressant. 

On  the  alimentary  canal  it  often  acts  disastrously. 
It  irritates  the  mucous  membrane  and  interferes  with 
the  reflex  activity  of  the  stomach  in  a  way  to  check  the 
normal  secretion  of  gastric  juice,  which  impairs  digestion. 

It  causes  constipation,  heavy  coating  of  the  tongue, 
and  foul  breath;  produces  a  bad  taste  and  a  pasty 
feeling  in  the  mouth,  causes  loss  of  appetite,  and  not 
infrequently  nausea  and  diarrhea. 

On  nutrition  it  also  acts  unfavorably  in  some  cases 
by  lessening  metabolic  changes  through  depressing  the 
nervous  system.  It  produces  unsteady  gait ;  myasthe- 
nia, particularly  noticeable  in  the  legs ;  depression  and 
often  loss  of  sexual  vigor;  forgetfulness  and  slight  de- 
grees of  aphasia,  usually  shown  in  the  misuse  of  words 
and  the  wrong  formation  of  sentences. 

On  the  temperature,  in  ordinary  doses,  it  has  no 
effect;  in  larger  doses  it  lowers  the  heat  of  the  body 
by  depressing  the  heart's  action  and  possibly  by  con- 
tracting the  arteries,  a  fact  apparently  established 
through  the  experiments  of  Brown-Sequard,  Mairet, 
and  Amory.* 

*  Ringer's  "Therapeutics,"  1886,  p.  147. 


Plate  20. 


Bromic  Acne  on  the  Back. 
Bromic  acne  induced  in  seven  days  by  30  grains  of  bromid  3  times  a 
day.  Individual  susceptibility  to  bromid,  combined  with  different  states 
of  sensitiveness  of  the  skin,  regulate,  to  a  large  degree,  the  amount  of  acne 
induced.  It  is  rarely  necessary,  under  modern  methods  of  administering 
bromid,  to  create  acne  to  the  extent  shown  in  this  illustration. 


DRUGS.  365 

Its  effects  on  the  skin  in  causing  acne — widespread, 
unsightly  eruptions  called  bromism— are  universally- 
known.  The  pustules  may  turn  into  circumscribed 
ulcerations  and  become  phagedenic.  Bromid  is  elim- 
inated very  slowly  and  escapes  unchanged.  It  is 
found  in  the  secretions,  including  the  sweat,  urine, 
semen,  milk,  and  feces  (Wood,  Hare,  Foster,  Brun- 
ton,  Ringer). 

According  to  Hare,*  "  Tissue  waste  is  decreased  when 
the  economy  is  under  the  influence  of  the  bromids." 
This  statement  the  distinguished  writer  evidently  did 
not  mean  to  apply  to  all  cases.  Some  patients  may 
take  the  bromid  in  from  thirty-  to  forty-grain  doses 
three  times  a  day  for  months  without  impairing  nutri- 
tion; but  it  has  been  my  experience  that  unless  care 
be  exercised  to  combat  its  toxic  effects  when  long  con- 
tinued, the  patient  loses  weight. 

I  am  not  of  the  opinion  that  the  bromids  tend  to 
the  conservation  of  tissue ;  but  feel  that  the  opposite, 
under  ordinary  conditions  and  when  the  drug  is  used 
alone,  is  more  often  the  case.  This  opinion  is  based 
on  a  daily  observation  of  its  use  in  several  hundred 
cases  of  all  types  and  under  all  conditions  during  many 
years  and  not  on  any  particular  scientific  investigation 
made  to  determine  the  point.  I  have  noted  that  most 
epileptics  gain  in  weight  when  given  a  less  quantity  of 
bromid  or  when  it  is  entirely  withdrawn. 

"  The  bromids  should  be  reserved  as  a  last  resort  or 
as  an  adjuvant.     Cures  by  the  bromid  treatment  are; 
not  to  be  expected.     As  a  practical  fact,  if  the  fits! 
are  not  controlled  by  sixty  grains  of  bromid  a  day, 
the  question  is  sure  to  arise  as  to  whether  the  epilepsy 
or  the  bromid  is  the  greater  evil.     It  is  a  frequent 
experience  to  see  patients,  brutalized  by  the  bromids, 
go  months  without  fits,   but  with   a  loss   of  mental' 
and  physical  activity ' '  (Church  and  Peterson) . 

*  "Practical  Therapeutics,"  1900,  p.  107. 


366  THE    MEDICAL    TREATMENT    OF    EPILEPSY. 

Weir  Mitchell  noticed  among  the  ill  effects  of  the 
bromids  "irritability,  increased  irritability  or  melan- 
cholia at  menstruation,  bad  temper,  suicidal  or  homi- 
cidal tendencies,  and  temporary  delusions  "  ("American 
Journal  of  the  Medical  Sciences,"  1896). 

On  the  whole,  I  know  of  no  drugs  save  those  which 
produce  habits  such  as  opium  and  cocain,  that  are  so 
universally  abused  as  the  bromids.  The  effects  of  these 
drugs  on  the  heart,  respiration,  gastrointestinal  canal, 
skin,  and  nutrition,  are  five  points  against  their  use 
in  epilepsy  compared  to  one  in  their  favor,  namely, 
their  power  of  lessening  overexcitability  of  nervous 
tissue.  The  question  naturally  arises,  Does  the  good 
they  accomplish  in  this  way  more  than  counterbalance 
their  injurious  effects  in  other  ways?  In  the  majority 
of  cases  the  answer  is,  Xo ;  in  some,  Yes. 

The  secret  of  obtaining  successful  action  with  the 
bromids  lies  in  the  judicious  method  of  their  adminis- 
tration, and  in  carefully  selecting  each  case  for  their 
use. 

As  an  emergency  remedy  in  suppressing  repeated 
convulsions  that  threaten  life,  like  serial  attacks  or 
status  epilepticus,  and  used  in  conjunction  with  other 
drugs,  the  bromids  are  always  valuable.  A  favorite 
prescription  for  this  purpose  is  the  following : 

r&  .     Potassium  bromid grs.  Lx. 

Chloral  hydrate grs.  xx. 

Morphia  sulphate gr.  J. 

Tinct.  opii  deod ff\,iv. 

Aqua  ad.  q.  s.  fiat 3  j. 

Sig. — Give  at  one  dose. 

This  dose  may  be  repeated  in  two  hours  if  necessary. 
The  treatment  in  such  cases  must  be  heroic ;  to  tem- 
porize may  be  fatal. 

In  •  psychic  epilepsy  or  in  the  psychic  epileptic 
equivalent  it  is  of  little  use.  In  the  latter  the  psycho- 
motor violence  is  too  great  to  respond  to  the  bromids 


Plate  21. 


Bromic  Acne  of  the  Face. 
The  prolonged  unguarded  use  of  bromid  may  cause  not  only  much 
disfigurement  but  phagedenic  ulcerations  that  cause  great  discomfort  and 
that  are  often  very  sluggish  in  healing.  It  is  seldom  necessary  to  push 
bromid  to  the  extent  required  to  cause  this  condition.  Rightly  admin- 
istered and  watched  in  its  effects,  it  need  not  cause  these  results. 


DRUGS.  367 

alone.  In  the  various  forms  of  epileptic  mania  they 
are  practically  without  virtue.  The  same  is  true  of 
their  use  in  most  of  the  epilepsies  due  to  recent  trauma. 
Here  they  may  be  especially  harmful  before  the 
operation  by  suppressing  important  phenomena  in- 
dicative of  the  seat  of  the  lesion.  After  operation, 
and  in  long-standing  traumatic  conditions,  they  are 
more  admissible. 

The  idiopathic  grand  mal  epileptic,  of  vigorous  con- 
stitution and  good  digestion,  does  best  under  the 
continuous  use  of  the  bromids.  Under  the  precautions 
I  am  about  to  outline,  such  patients  may  take  them 
continuously  for  years  without  harm.  The  size  of  the 
initial  dose  must  be  regulated  by  the  character  of  the 
fit  and  by  the  manner  in  which  the  drug  is  given; 
beyond  the  third  or  fourth  year,  age  has  but  little  to 
do  with  it. 

In  most  cases  it  should  be  given  to  the  point  of 
toleration  or  to  the  point  required  to  control  the 
attacks.  This  can  be  determined  only  after  trial. 
Unless  the  attacks  are  threatening  in  frequency  and 
severity,  it  is  best  to  begin  with  from  five  to  ten  grains 
three  times  a  day.  Prescribed  in  a  watery  solution  of 
a  definite  strength  is  the  best  form  for  giving  it  alone. 
In  this  way  a  drachm  may  be  made  to  represent  any 
amount  the  patient  is  to  have. 

The  hour  of  administration  is  important.  A  sys- 
tematic record  of  all  seizures,  day  and  night,  should  be 
kept.  After  a  little  while,  the  hour  at  which  attacks 
are  most  likely  to  occur  can  be  determined.  If  they 
are  more  prone  to  occur  at  night  just  after  the  patient 
falls  asleep,  the  medicine  should  be  given  early  in  the 
evening ;  if  they  come  after  midnight,  it  should  be  taken 
on  retiring,  or  about  9  a.m.  ;  if  they  have  a  matutinal 
tendency,  as  they  so  often  do — occurring  just  after  the 
patient  gets  up  in  the  morning — the  largest  dose  should 
be  given  before  the  patient  gets  out  of  bed. 


368  THE    MEDICAL    TREATMENT    OF    EPILEPSY. 

Nocturnal  epileptics  should  get  larger  doses  at  night 
than  during  the  day,  while  the  converse  is  true  with 
those  of  diurnal  habits.  The  former,  if  taking  from 
ten  to  fifteen  grains  during  the  day,  should  have 
double  the  quantity  on  the  approach  of  the  seizure 
period  at  night,  and  the  same  with  the  latter  during 
the  day. 

The  bromid  salts  should  not  be  administered  in 
close  conjunction  with  meal  hours — an  hour  before  or 
after  is  best.  They  act  more  promptly  on  an  empty 
stomach.  If  habitually  taken  before  meals,  somewhat 
smaller  doses  may  suffice.  They  should  be  given  in 
plenty  of  water,  plain  or  carbonated,  such  as  Vichy 
or  Apollinaris.  Their  effects  are  much  enhanced  when 
given  in  this  way.  The  larger  the  quantity  of  water 
taken,  the  better. 

Their  administration  once  begun  should  not  be' 
interrupted  unless  the  patient's  condition  imperatively 
demands  it.  Mothers  who  are  taking  the  bromids 
should  not  nurse  their  babies.  Any  severe  illness, 
such  as  typhoid  fever,  that  saps  the  patient's  strength, 
should  cause  their  gradual  withdrawal. 

If  the  attacks  can  be  held  in  check  by  the  bromids 
for  two  years  or  more,  they  may  be  reduced  in  quantity 
at  the  end  of  that  time.  Sudden  withdrawal  is  never 
advisable — to  do  this  is  to  invite  grave  disaster  in  the 
way  of  status  epilepticus. 

The  prevention  of  bromid  intoxication  is  always  de- 
sirable. Besides  the  discomfort  and  disfigurement  it 
entails,  it  is  a  telltale  of  some  disease.  Except  in  the 
rarest  instances,  it  is  not  necessary  to  push  the  drug 
to  the  toxic  limit. 

By  beginning  with  small  doses  which  the  patient  can 
assimilate,  'and  being  watchful  for  the  first  symptoms 
of  its  effects  on  the  skin,  by  keeping  the  digestion  in 
good  condition,  the  intestinal  canal  free  from  the 
products  of  putrefactive  changes  and  so  lessening  the 


DRUGS.  369 

danger  of  auto-intoxication,  and  by  habitually  guard- 
ing against  constipation,  and  easing  the  disquiet  so 
often  attendant  upon  the  menstrual  flow,  we  can  keep 
down  any  marked  accessions  to  the  frequency  and 
severity  of  epileptic  attacks,  and  so  obviate  the  neces- 
sity for  the  temporary  heavy  drugging  that  always 
ends  in  pronounced  intoxication. 

The  chief  indication  lies  in  directing  treatment  to  the 
numerous  conditions  that  incite  epileptic  phenomena 
to  greater  activity,  and  we  should  not  rely  on  the 
bromids  to  suppress  them  irrespective  of  the  cause  of 
their  origin.  No  surgeon  would  think  of  applying  a 
poultice  over  a  splinter  to  deaden  the  pain;  he  would 
first  remove  the  cause. 

The  same  principle  applies  in  many  cases  of  epilepsy. 
The  eliminative  system,  the  skin,  kidneys,  and  bowels, 
demand  especial  attention.  The  price  of  failure  may 
often  be  found  in  the  neglect  of  these.  A  congenitally 
weak  and  hypersensitive  nervous  system  is  delicately 
enough  adjusted  to  lose  its  balance  (in  a  fit)  under 
the  excitation  of  poisons  due  to  imperfect  elimination. 
Free  elimination  also  greatly  lessens  the  danger  of 
bromism. 

Bromic  acne  may  be  further  prevented  by  the  use 
of  Liquor  arsenic alls  given  with  the  bromid,  as  recom- 
mended by  Echeverria  in  1870;  and  by  daily  cold  or 
tepid  baths  followed  by  brisk  rubbing,  and  outdoor 
life.  Turkish  baths  in  persons  of  strong  vitality  are 
useful.  In  other  cases,  facial  massage  and  steaming 
lessen  the  rash  very  materially.  These  are  especially 
valuable  on  sensitive  skins. 

The  hypodermic  use  of  the  bromid  salts  is  rarely 
called  for  in  epilepsy.  Occasionally  it  is  employed  in 
status  epilepticus,  and  usually  causes  abscess  and  a 
scar.  The  hypodermic  should  be  given  in  the  but- 
tocks or  thighs. 

The  coefficient  forms  of  the  bromid  treatment  include 
24 


370  THE    MEDICAL    TREATMENT    OF    EPILEPSY. 

the  use  of  other  remedies  along  with  the  bromids,  and 
the  latter  under  various  modifications.  It  is  a  common 
practice  to  give  several  of  the  bromid  salts  in  combina- 
tion, usually  potassium,  sodium,  and  ammonium;  the 
two  former  in  ten-grain  doses,  the  latter  in  five-grain 
doses.  With  them  may  be  given  small  doses  of  bicar- 
bonate of  soda  and  Liquor  potassii  ar senilis. 

When  the  attacks  are  mostly  at  night,  belladonna 
in  some  form  is  useful.  A  good  formula  includes  in 
each  dose  two  minims  of  the  tincture  of  belladonna, 
from  ten  to  fifteen  grains  of  the  bromid  of  potassium, 
and  five  grains  of  chloral  hydrate.  In  the  epilepsies 
attendant  upon  the  menstrual  epoch,  I  have  found 
the  bromid  of  sodium  in  liberal  doses  most  valuable. 

The  bromid  of  strontium  has  been  used  with  varying 
success,  succeeding  in  some  cases  after  the  other  salts 
had  lost  their  virtue,  or  had  failed  in  the  first  instance 
to  give  relief.  It  should  be  given  in  from  fifteen-  to 
twenty-grain  doses  in  conjunction  with  smaller 
amounts  of  the  ammonium  and  sodium  salts.  Some 
patients  will  bear  it  in  drachm  doses  without  harm. 
Roche  commends  it  highly;  others  fail  to  find  any 
specific  virtue  in  it. 

A  change  from  one  bromid  preparation  to  another 
in  many  cases  from  time  to  time  proves  beneficial. 

The  hypochlorization  method  devised  by  Toulouse 
and  Richet  consists  in  salting  the  patient's  food  with 
sodium  bromid  instead  of  ordinary  sodium  chlorid,  the 
former  tasting  so  like  the  latter  as  to  be  a  very  ac- 
ceptable substitute  for  it.  Upon  reaching  the  stom- 
ach, the  bromid  salt  is  broken  up  in  the  same  way 
that  sodium  chlorid  enters  the  metabolic  formation  of 
hydrochloric  acid- under  normal  conditions.  Entering 
the  stomach  at  a  time  of  great  digestive  activity,  the 
sodium  bromid  performs  the  function  of  the  table  salt, 
and  is  so  readily  absorbed  as  to  promote  rapid  sedation 
in  practically  half  the  dosage  required  when  adminis- 
tered in  the  ordinary  way. 


DRUGS.  371 

The  disadvantage  of  this  method  of  treatment  lies 
in  specially  preparing  the  patient's  food  to  keep  it 
free  from  chlorid  of  sodium.  It  is  easier  to  do  this 
in  an  institution  than  in  a  private  home.  Patients  of 
sufficient  intelligence  may  carry  a  small  measure . 
holding  the  amount  of  the  sodium  bromid  they  should 
take,  and  a  supply  of  the  latter,  salting  their  food  at 
each  meal.  Under  this  method  ten  grains  of  the 
bromid  of  sodium  is  as  effective  as  twenty  grains 
given~in  the  usual  way,  making  the  plan  one  of 
economy. 

There  is  occasion  (Richet)  in  hypochlorization  to 
distinguish  the  therapeutic  from  the  physiologic 
effect.  According  to  Fere,*  the  disadvantage  of  the 
latter  may  outweigh  the  advantages  of  the  former. 
While  this  method  has  some  value,  its  efficacy  is  yet 
on  trial.  Its  adoption  is  difficult  in  private  homes, 
while  its  employment  in  any  event  is  open  to  the 
objection  of  the  bromids  generally.  No  matter  how 
they  are  administered,  constant  auxiliary  treatment 
of  the  gastrointestinal  tract  and  the  cutaneous  system 
is  required  to  guard  against  the  evil  effects  of  in- 
toxication. 

Special  Bromin  Preparations. — During  the  past  fe 
years,  very  excellent  results  have  been  obtained  fro 
a  preparation  of  bromin  in  chemical  combination  wit 
the  fatty  acids  of  sesame  oil,  in  which  the  irritant 
qualities  of  the  element  are  entirely  absent — bromipin. 
Its  greatest  value  has  been  found  in  feeble  or  asthenic 
cases.  Given  in  the  form  of  an  emulsion  in  such  cases 
it  is  a  good  reconstructive,  usually  causing  a  gain  in 
weight.  A  good  formula  is  bromipin  four  ounces; 
syr.  simplex  four  ounces;  spirits  of  peppermint  four 
drachms ;  mucilage  of  acacia,  enough  to  make  sixteen 
ounces.  The  dose  for  an  adult  is  two  or  three  table- 
spoonfuls  three  times  a  day  after  meals. 

*  "Extrait  des  comptes  rendus  des  sciences  de  la  Societe  de  Biologie," 
Feb.  28,  1903,  t.  iv,  p.  279. 


372  THE    MEDICAL    TREATMENT    OF    EPILEPSY. 

Among  its  advantages  are  these:  It  may  be  given 
hypodermically  in  status  epilepticus  without  the  risk 
of  abscess,  a  desirable  form  of  administration  when 
the  patient  is  in  a  comatose  and  critical  condition  as 
the  result  of  repeated  seizures ;  its  entire  freedom  from 
irritating  effects  upon  the  gastrointestinal  canal;  and 
its  failure  under  maximum  dosage  to  cause  bromic  acne. 

In  children  it  may  be  employed  to  great  advantage 
combined  with  linseed  or  Irish  moss  tea,  and  given  in 
the  form  of  enemata  (Rahn).  In  infants  the  dose  is 
one  gramme  for  each  month  in  age;  in  children  the 
dose  is  from  ten  to  fifteen  grammes.  Instead  of  using 
a  10  per  cent,  solution  for  this  purpose,  one  of  33 
per  cent,  may  be  used  when  rapid  sedation  is  required. 

When  given  in  the  form  of  enemata,  the  patient 
should  lie  on  the  left  side  with  legs  drawn  up ;  a  rubber 
cannula  is  introduced  about  twelve  centimeters  and 
the  fluid  slowly  injected.  It  may  be  used  in  this  way 
for  two  or  three  weeks,  night  and  morning. 

The  chief  obstacle  to  the  use  of  bromipin  at  the 
present  time  is  its  cost,  which  is  five  times  that  of  the 
bromid  salts. 

How  the  Bromin  Preparations  Act. — Notwithstanding 
the  length  of  time  that  we  have  known  the  bromids 
to  lessen  the  tendency  to  spontaneous  discharges,  we 
have  no  precise  knowledge  of  the  method  of  their 
action.  That  they  act  in  consequence  of  the  presence 
of  the  element  bromin,  there  can  be  no  doubt.  Bro- 
mid is  said  to  cause  contraction  of  the  small  vessels; 
but  if  it  has  this  effect,  it  is  not  likely  that  its  in- 
fluence on  epilepsy  is  thus  produced  (Gowers).  It  is 
evident  that  it  must  be  carried  by  the  plasma  to  the 
nerve  structures  of  the  brain.  There  it  seems  to  re- 
strain the  undue  tendency  of  the  constituents  of  the 
nerve  substance  to  escape  to  combine  with  the  oxygen 
of  the  plasma.  If  it  acts  in  this  way,  it  is  not  known 
just  how.     It  may  do  so  through  the  mere  effect  of 


DRUGS.  373 

its  presence,  or  by  yielding  its  bromin  to  combine  with 
constituents  of  the  nerve  elements.  All  knowledge 
along  this  line  is  as  yet  speculative. 

Bromin  is  a  strong  disinfectant  and  it  may  eventu- 
ally be  found  that  its  value  in  epilepsy  is  due  to  some 
extent  to  its  power  of  neutralizing  morbific  agents  in 
the  blood.  This  seems  fully  as  tenable  a  theory  at 
this  time  as  that  which  assumes  that  the  presence  of 
bromin  in  the  nerve  structures  serves  to  reduce  their 
morbid  affinity  for  oxygen. 

Whatever  its  mode  of  action,  it  is  often  feeble  and 
uncertain  and  always  transient,  while  its  elimination 
from  the  system  is  not  accomplished  under  two  to 
three  weeks,  so  that  while  its  beneficial  effects  are 
brief,  its  prejudicial  effects  are  often  indefinitely 
sustained. 

If  epilepsy  (as  it  is  now  so  generally  believed)  is 
due  to  "an  abnormal  readiness  of  the  cells  of  the  t 
cortex  for  action,"  and  if  the  bromids  lessen  their 
tendency  to  discharge — no  matter  how — we  can  see 
that  the  reason  they  so  often  fail  to  effect  a  cure  is 
that  they  do  not  remedy  an  elemental  cytologic  defect, 
but  merely  lessen  or  suppress  nervous  hyper-excita- 
bility. But  even  this  is  valuable,  for,  during  sup- 
pression, time  is  given  for  more  tedious  but  more 
lasting  forms  of  treatment  to  become  of  permanent 
service. 

The  Opium-bromid  Treatment. — Opium  was  recom- 
mended in  epilepsy  by  Paracelsus  in  the  fifteenth 
century,  and  by  Crato  and  Quercetanus  in  the  six- 
teenth century,  while  De  Haen  reported  a  patient 
cured  by  a  large  dose  of  laudanum,  a  sequence  of 
doubtful  credibility  (Gowers).  Opium  alone  is  seldom 
used  in  epilepsy.  While  its  power  to  suppress  the 
attacks  temporarily  may  not  be  questioned,  its  danger 
in  other  respects  is  great. 

In  1893  Flechsig  originated  a  method  of  employing 


374  THE    MEDICAL    TREATMENT    OF    EPILEPSY. 

opium  and  bromid  in  conjunction  in  epilepsy.  The 
treatment  consisted  in  keeping  the  patient  in  a  state 
of  mild  opium  narcosis  for  six  weeks,  beginning  with 
a  small  amount  daily  and  increasing  it  to  fifteen 
grains  at  the  end  of  that  time.  The  opium  is  then 
suddenly  withdrawn  and  bromid  substituted  in  from 
1 20-  to  130-grain  doses  daily  for  two  months,  after 
which  the  amount  is  diminished  gradually  to  thirty 
grains  a  day. 

Flechsig  recommended  this  treatment  only  in 
chronic  cases  in  which  the  bromids  alone  had  failed, 
and  cautions  that  the  patient  be  carefully  watched 
during  the  whole  course  of  treatment. 

In  my  experience  ,the  plan  was  of  little  use.  Many 
patients  of  the  type  in  which  it  is  safe  to  use  it  could 
not  endure  such  heroic  medication.  Out  of  twelve 
submitted  to  it,  two  had  to  be  withdrawn  before  the 
end  of  the  second  week  on  account  of  the  extreme 
stupefaction.  In  the  remaining  ten,  six  showed  no 
improvement  at  the  end  of  the  bromid  course,  two 
had  their  attacks  temporarily  suppressed,  while  in  the 
remaining  two  they  were  lessened  in  frequency  and 
severity.  All  of  them  were  practically  incapacitated 
during  the  treatment  through  mental  stupor  and 
unfitness  for  physical  exertion. 

The  verdict  of  those  who  have  tried  the  method  is 
almost  uniformly  unfavorable,  including  Donath, 
Bohme,  Landois,  Luske,  Kathe,  Homen,  Liehen, 
Warda,  and  Bratz.  The  latter  in  the  treatment  of  forty- 
six  cases  met  with  three  cases  of  status  epilepticus  and 
several  cases  of  severe  mental  depression  (Gowers). 
Some  writers  report  more  favorably. 

In  my  experience  the  attacks  of  epilepsy  can  be 
materially  reduced  in  this  way  in  almost  every  case 
that  has  shown  itself  obstinate  to  the  ordinary  bromid 
plan  (Collins). 

The  treatment  of    Flechsig  is  of    value  for  many 


drugs.  375 

patients,  especially  in  old  and  obstinate  cases  when  all 
other  agents  have  proved  ineffectual  (Church  and 
Peterson). 

In  this  connection  the  occasional  effects  of  morphia 
in  epilepsy  should  be  mentioned.  Bad  effects  are  apt 
to  follow  when  the  period  of  epileptic  coma  happens 
to  coincide  with  the  sleep  induced  by  the  morphin. 
Gowers  mentions  a  case  in  which  an  epileptic  about 
to  undergo  a  surgical  operation  was  given  a  quarter  of 
a  grain  of  morphin  to  relieve  great  pain.  As  the  drug 
was  beginning  to  take  effect,  the  patient  had  a  seizure 
and  immediately  passed  into  profound  coma  that 
rendered  artificial  respiration  necessary  for  an  hour. 

Codein  in  conjunction  with  the  bromids  has  been 
used  quite  successfully  in  lessening  the  frequency  and 
severity  of  attacks  in  chronic  cases.  Its  failure  to 
arrest  secretion  in  the  respiratory  and  intestinal  tract 
is  a  point  in  its  favor  over  opium. 

Many  epileptologists  deny  the  value  of  codein  in 
epilepsy.  It  cannot  be  claimed  to  have  any  curative 
properties.  In  a  feebler  way  than  opium  it  tends  only 
to  suppress  epileptic  phenomena  and  may  be  tried 
after  other  remedies  have  failed. 

It  is  never  safe  to  employ  opium  in  any  form  in 
epilepsy  unless  the  patient  is  under  a  physician's  con- 
stant care.  Disastrous  consequences  may  develop  in 
any  case. 

Borax. — Next  to  the  bromids  many  believe  that 
borax  (sodium  borate)  enjoys  favorable  distinction  as 
an  anti-epileptic  remedy.  It  was  first  suggested  and 
used  by  Gowers  in  1879,*  who  has  since  remained  a 
believer  in  its  efficacy.  It  may  be  given  in  combination 
with  bromid  and  deserves  a  trial  in  obstinate  cases. 
The  dose  is  from  fifteen  to  thirty  grains  three  times  a 
day  when  given  alone.  If  given  in  combination  with 
bromid,  the  dose  may  be  larger. 

*  " Goulstonian  Lectures,"  "Lancet,"  1879,  Vol.  1. 


376  THE    MEDICAL    TREATMENT    OF    EPILEPSY. 

In  some  patients  it  acts  unfavorably  by  causing 
diarrhea  with  dysenteric  evacuations  if  the  dose  is  too 
large  at  the  beginning.  A  reduction  in  the  quantity 
causes  untoward  symptoms  to  disappear.  It  has  been 
given  as  high  as  120  grains  a  day,  though  not  for  any 
length  of  time. 

Another  complication  likely  to  appear  is  psoriasis, 
though  not  under  several  months'  administration. 
The  addition  of  arsenic  to  the  borax  will  cause  the 
psoriasis  to  disappear.  In  this  class  of  cases  it  is 
only  after  the  bromid  has  failed  that  we  need  employ 
borax.  Gowers  mentions  an  obstinate  case  that 
yielded  to  borax  and  tincture  of  gelsemium  in  com- 
bination after  numerous  other  remedies  had  failed, 
the  former  being  given  in  twelve-grain  and  the  latter 
in  five-minim  doses. 

Mairet*  sums  up  his  conclusions  concerning  the  use 
of  borax  in  epilepsy  as  follows: 

1.  Borate  of  soda  may  have  a  real  utility  in  the 
treatment  of  epileptic  attacks,  which  it  may  diminish 
or  even  entirely  suppress  for  many  months. 

2.  Borate  of  soda  succeeds  better  in  symptomatic 
epilepsies  than  does  the  bromid  of  potassium. 

3.  Bromid  of  potassium  acts  better  on  the  epi- 
lepsy neurosis. 

Borate  of  soda  was  tried  at  the  Colony  in  ten  care- 
fully selected  cases,  all  of  an  obstinate  character. 
The  initial  dose  was  ten  grains  three  times  a  day, 
increased  later  to  fifteen  grains.  In  three  cases  only 
was  there  a  diminution  in  the  number  of  seizures. 
Upon  the  gastrointestinal  tract  its  evil  effects  were 
noted  in  nearly  all  cases  at  one  time  or  another.  Its 
cumulative  tendency  gave  use  to  persistent  attacks 
of  furunculosis,  which  led  to  its  abandonment. 

Chloral  hydrate  is  of  little  use  in  the  treatment  of 
epilepsy  ordinarily.     I  have  found  it  of  greatest  value 

*  "Le  Progrfcs  medical,"  No.  41,  Oct.  10,  1901. 


drugs.  377 

in  cases  of  mental  disturbance  (epileptic  mania), 
and  in  obstinate  insomnia,  which  is  not  often  encoun- 
tered in  epilepsy  independent  of  disturbed  mental  states. 
Some  patients  who  show  a  psychic  aura  several  days 
prior  to  the  attack,  who  are  mildly  excited,  loquacious, 
eyes  unusually  bright,  pulse  quickened,  and  face 
flushed,  are  good  subjects  for  its  use.  It  is  best  given 
with  bromid  acacia,  simple  syrup,  or  syrupus  pruni 
virginiance  as  adjuvants.  Its  value  in  nervous  in- 
somnia may  be  enhanced  by  the  addition  of  one-eighth 
or  one-sixth  of  a  grain  of  morphin  to  the  dose. 

Rarely  we  may  find  an  epileptic  exhibiting  for  weeks 
at  a  time  the  pre-convulsive  symptoms  enumerated 
above.  Three  cases  of  the  kind  have  come  under  my 
care.  Chloral  hydrate  in  eight-  or  ten-grain  doses  two 
to  three  times  a  day  was  more  effective  in  them  than 
anything  else. 

In  serial  attacks  and  in  status  epilepticus  cases  that 
resist  all  other  measures,  chloral  hydrate  is  often  of 
great  service.  The  contingency  being  great,  the 
remedy  at  times  must  be  used  heroically.  In  the  first 
stages  of  status  epilepticus  it  may  be  administered  by 
the  mouth.  When  coma  supervenes  with  the  attacks 
continuing,  it  should  be  given  by  the  rectum  in  con- 
junction with  bromid.  The  moment  it  is  noted  that 
the  sedation  is  controlling  the  attacks,  its  reduction 
should  be  begun.  It  is  always  dangerous  to  give 
chloral  when  cardiac  failure  is  imminent.  If  a  first 
dose  of  thirty  grains  is  not  effective  in  serial  attacks 
or  status  epilepticus,  a  second  may  be  given  in  three 
hours,  the  heart  permitting.* 

Amylene  hydrate  was  tried  by  Weber  in  seventy 
cases  of  long  standing  and  equally  divided  as  to  sex. 
Most  of  them  received  the  drug  in  from  half  to  two 
drachm  doses  daily.  Eighty  per  cent,  showed  no 
marked   variation   in   their   convulsions;     fifteen   per 

*  See  chapter  on  Status  Epilepticus. 


378  THE    MEDICAL    TREATMENT    OF    EPILEPSY. 

cent,  showed  a  decided  increase;  while  five  per  cent, 
only  showed  a  decrease.  Except  in  the  last  five  cases, 
all  showed  disturbance  in  general  health,  drowsiness, 
mental  sluggishness,  and  digestive  disorders,  which  led 
to  the  drug  being  discontinued.  A  diminution  in 
attacks  occurred  in  ten  per  cent,  of  the  same  cases 
under  resumption  of  bromid. 

Wildermuth  speaks  favorably  of  amylene  hydrate 
in  cases  in  which  bromid  has  failed,  provided  the  course 
of  treatment  is  short.  In  from  four  to  six  weeks  the 
evil  effects  noted  by  Weber  begin  to  appear.  It 
occasionally  acts  better  in  status  epilepticus  than 
.chloral,  and  according  to  Wildermuth  is  often  effective 
in  the  eclamptic  attacks  of  children. 

Nitroglycerin  is  serviceable  in  cases  of  senile  epilepsy 
with  evidences  of  arteriosclerosis;  not  so  much  on 
account  of  its  effects  upon  the  attacks,  as  in  lessening 
the  extreme  discomfort  that  not  infrequently  precedes 
and  attends  them  in  such  cases. 

A  man,  sixty-five  years  old,  of  voracious  appetite, 
plethoric,  and  with  whip-cord  arteries,  suffered  the 
most  distressing  pain  in  the  precordial  region  for  hours 
before  an  epileptic  convulsion.  He  was  given  t-^-q  of 
a  grain  of  nitroglycerin  three  times  a  day,  his  diet  and 
exercise  regulated,  and  at  the  end  of  three  months  he 
had  experienced  a  most  positive  relief — his  convul- 
sions (which  were  less  in  number)  being  attended  with 
none  of  the  former  painful  manifestations. 

Nitroglycerin  acts  rapidly  and  the  effects  are  of 
short  duration,  requiring  that  it  be  given  every  three 
or  four  hours. 

It  may  also  be  employed  in  conjunction  with  bromid 
in  the  liquor  trinitrini  of  the  pharmacopeia,  a  one  per 
cent,  solution  of  nitroglycerin  in  alcohol.  To  insure 
its  stability,  it  must  be  rendered  acid,  which  can  be 
done  by  adding  from  ten  to  fifteen  minims  of  dilute 
hydrobromic  acid  to  each  dose. 


drugs.  379 

It  is  also  often  useful  in  the  periodic  headaches  that 
accompany  epilepsy.  It  is  also  of  great  value  in  com- 
bination with  bromid  in  cases  that  show  a  feeble 
circulation,  slow  pulse,  coldness,  and  pallor  of  the 
extremities. 

Gowers  speaks  of  its  good  effects  in  attacks  of 
momentary  unconsciousness  in  children.  It  has  long 
been  my  belief  that  such  attacks  were  not  infrequently 
associated  with  pathologic  conditions  in  the  circulatory 
system.  I  recall  three  boys  between  nine  and  twelve 
years  in  whom  marked  improvement  followed  the 
exhibition  of  heart  tonics.  All  had  normally  a  very 
slow  pulse.  In  two  of  them  the  beat,  which  I  had 
opportunity  to  count,  fell  from  60  to  48  a  minute 
at  the  beginning  of  the  attack. 

Chloretone. — -The  results  of  chloretone  in  epilepsy 
are  not  unlike  those  of  Flechsig's  treatment.  Weeks 
tried  it  in  six  chronic  cases,  with  the  result  that  when 
pushed  to  as  high  dosage  as  seemed  safe,  it  lessened 
the  frequency  and  severity  of  the  attacks  in  most  of 
them.  Coincidently  it  caused  marked  somnolence, 
headache,  and  vertigo.  Pallor  was  noticed  in  nearly 
all  who  took  it.  Weeks  advises  that  the  patient  be 
brought  under  its  influence  as  rapidly  as  possible,  after 
which  the  dose  should  be  gradually  reduced.  In 
most  cases  six  grains  three  times  a  day  is  sufficient 
to  prolong  the  effects  obtained. 

Zinc  is  among  the  older  remedies  used  in  epilepsy. 
It  was  prescribed  more  than  a  century  ago.  In  the 
pre-bromid  days  it  took  first  rank  as  a  therapeutic 
measure  and  was  praised  by  Herpin,  who  is  reputed  to 
have  effected  so  large  a  percentage  of  cures. 

Its  action  is  analogous  to  bromid,  though  less  power- 
ful. It  lessens  reflex  action,  influences  the  functions 
of  the  cerebral  hemispheres,  and  generally  acts  best 
in  the  milder  cases.  Of  all  its  salts,  oxid,  lactate 
citrate,    sulphate,    and   bromid,    the   former   is   most 


380  THE    MEDICAL    TREATMENT    OF    EPILEPSY. 

generally  used.  Individual  susceptibility  to  it  varies 
greatly.  Some  patients  can  take  eight  or  ten  grains 
with  impunity;  in  others,  two  or  three  grains  cause 
nausea.  It  is  best  administered  in  pill  form.  The 
oxid  salt  is  doubtless  converted  into  chlorid  in  the 
stomach,  which  is  too  slowly  absorbed  to  become  an 
irritant. 

It  was  tried  at  the  Colony  in  ten  cases  in  conjunction 
with  salol.  In  all  of  the  cases  selected  there  was 
muscular  tremor  or  marked  nervous  irritability.  After 
a  fair  trial,  in  a  small  percentage  of  the  cases  there 
were  fewer  attacks,  but  the  decrease  was  not  main- 
tained on  the  withdrawal  of  the  drug. 

Urethan  has  been  praised  highly  by  Jacobi  as  a 
remedy  in  epilepsy.  I  selected  six  cases  of  the  idio- 
pathic disease  for  its  trial;  three  of  the  patients  were 
subject  to  diurnal,  three  to  nocturnal  attacks.  In  the 
diurnal  cases  twenty  grains  were  given  each  patient 
three  times  a  day;  in  the  night  cases  twenty  grains 
morning  and  noon,  and  forty-five  grains  at  night. 
The  trial  extended  over  thirty  days,  during  which 
notes  on  temperature,  skin,  pulse,  respiration,  reflexes, 
circulation,  headache,  and  mental  condition  as  affected 
by  the  drug,  were  kept.  In  no  case  did  it  act  harm- 
fully in  any  respect.  One  patient  had  no  attacks 
while  taking  it,  having  had  seven  during  the  previous 
month;  two  had  their  attacks  reduced  to  two-fifths 
their  former  frequency;  three  remained  unchanged. 
I  regard  urethan  as  worthy  of  trial  in  cases  in  which 
the  bromids  give  no  benefit. 

Solanum  carolinense  was  introduced  by  Xapier 
of  South  Carolina  a  few  years  ago.  It  was  given  to 
ten  men-  and  eight  women  at  the  Colony  for  a  period 
of  two  months.  In  six  of  them  there  was  a  consider- 
able reduction  in  the  number  of  attacks  during  the 
period  of  treatment.  Collectively  they  had  133  attacks 
during  the  two  months  preceding  the  use  of  the  drug, 


DRUGS.  381 

and  95  during  an  equal  period  while  taking  it.  In 
one  patient  the  improvement  was  sufficiently  marked 
to  warrant  its  continuance  over  a  period  of  eighteen 
months.  During  four  months  prior  to  treatment  he 
had  18  grand  mat  attacks.  The  first  month  under 
treatment,  he  had  none;  the  second,  five;  the  third, 
three;  while  during  the  following  fifteen  months  he 
had  but  one.  The  drug  was  then  discontinued,  with 
the  result  that  during  the  next  five  months  he  had 
seven  seizures. 

Among  the  remaining  eleven  cases  one  patient  died 
in  status  epilepticus,  while  ten  experienced  no  bene- 
ficial results. 

A  second  trial  of  the  drug  in  eight  selected  cases 
failed  to  produce  results  as  good  as  those  above. 
My  experience  with  solanum  carolinense  leads  me  to 
believe  that  we  have  in  it  an  effective  remedy  in 
selected  cases.  Those  taking  it  should  possess  a 
strong  physique,  good  digestive  powers,  and  show  as 
little  mental  impairment  as  possible.  Severity  of 
attacks  makes  no  difference.  It  is  given  in  the  form 
of  a  fluid  extract  in  doses  of  half  a  drachm  to  a  drachm 
three  times  a  day. 

Simulo. — The  investigations  of  Eulenberg  ("Thera- 
peutic Gazette,"  Oct.  15,  1888)  directed  attention  to 
the  use  of  simulo  in  epilepsy.  It  is  made  from  a 
South  American  plant  of  the  hyssop  family  and  is 
given  in  the  form  of  a  tincture  in  two-  or  three-drachm 
doses  three  times  a  day.  It  has  attained  considerable 
prominence  in  cases  in  which  bromid  was  not  well 
borne  alone,  and  is  often  valuable  when  prescribed 
in  conjunction  with  it. 

' '  I  would  say  of  simulo  that  it  deserves  trial  in 
most  cases ;  that  it  is  perfectly  harmless,  which  cannot 
be  said  of  the  bromids,  belladonna,  and  some  other 
drugs ;  .  .  .  .  that  in  most  cases  it  has  no  effect 
at  all"  (Peterson). 


382  THE    MEDICAL    TREATMENT    OF    EPILEPSY. 

It  was  tried  for  one  month  in  ten  cases  under  my 
care,  improvement  resulting  in  two  of  them.  During 
the  month  preceding  its  trial,  these  two  patients  had 
194  seizures;  during  treatment,  123;  and  during  the 
month  following,  163.  The  remaining  eight  patients 
had  80  seizures  in  the  month  before  treatment,  109 
during  it,  and  114  during  the  month  following. 
These  results  were  obtained  under  small  doses  to  test 
its  constitutional  effects,  which  were  nil.  On  in- 
creasing the  quantity  to  two  and  three  drachms  three 
times  a  day,  there  was  still  failure  to  produce  any 
toxic  effects,  while  a  further  reduction  in  the  attacks 
was  induced. 

On  the  whole,  simulo  and  solatium  carolinense  are 
well  worth  trial  in  cases  that  are  over-susceptible  to 
bromid  intoxication,  or  in  which  bromid  does  not 
lessen  or  suppress  the  attacks.  They  have  merit  in 
being  comparatively  harmless  under  anything  like 
rational  administration. 

Trional.— The  very  general  advocacy  of  this  drug 
in  epilepsy  a  few  years  ago  led  me  to  try  it  in  7  noc- 
turnal cases,  the  trial  lasting  thirty  days,  the  patients 
being  kept  thoroughly  under  its  full  effects  all  the  while. 
It  was  first  administered  in  twenty-grain  doses  fol- 
lowed by  thirty  grains  of  effervescing  Vichy  salts  in  a 
glass  of  hot  water.  The  Vichy  so  enhanced  its  action 
that  ten-grain  doses  of  the  trional  sufficed  to  keep  its 
full  physiologic  effects  in  view.  Beyond  some  dulling 
of  cerebration,  vertigo,  and  general  muscular  weakness, 
no  evil  effects  were  noted;  nor  did  it  have  any  ap- 
preciable effect  on  the  disease  itself. 

In  Case  I  there  were  114  attacks  before  treatment, 
96  during  treatment,  and  99  after  (each  number  in 
thirty  days);  in  Case  II,  8  before,  4  during,  and  6 
after;  in  Case  III,  5  before,  11  during,  and  9  after; 
in  Case  IV,  4  before,  4  during,  and  6  after;  in  Case  V, 
51  before,  59  during,  and  59  after;  in  Case  VI,  35  before, 


DRUGS.  383 

18  during,  and  17  after;  in  Case  VII,  5  before,  3  during, 
and  3  after. 

I  mention  these  negative  results  particularly  to  call 
attention  to  the  apparent  inertness  of  a  remedy  that 
exercises  so  great  an  influence  on  the  brain.  Not- 
withstanding its  ability  to  induce  profound  sleep,  it 
showed  no  power  to  check  the  convulsions. 

Iron. — The  administration  of  iron  in  epilepsy  has 
been  opposed  by  many  distinguished  authorities, 
including  Hughlings- Jackson  and  Brown-Sequard,  who 
held  that  it  increased  the  attacks. 

Indiscriminately  used,  this  may  be  true,  but  I 
have  found  its  action  beneficial  in  certain  cases.  Its 
use  is  especially  advised  in  chlorotic  or  anemic  young 
women  who  develop  epilepsy,  or  whose  epileptic 
attacks  become  accentuated  at  puberty.  I  have  also 
noted  its  good  effects  in  cases  of  pernicious  anemia 
in  older  persons.  If  it  is  substituted  for  bromid,  the 
effect  of  the  cessation  of  the  bromid  must  not  be  as- 
cribed to  the  influence  of  the  iron. 

Gowers  believes  its  beneficial  influence  is  not  con- 
fined to  its  hematinic  effect;  that  it  has  a  specific 
action  on  the  nerve  centers  similar  to  that  caused  by 
other  metals.  Meyer  and  Williams  found  that  it  had 
such  action  by  injecting  the  tartrate  of  soda  and  iron 
into  the  blood  of  animals,  with  the  result  that  it  caused 
paralysis  of  central  origin,  the  excitability  of  the 
muscles  and  peripheral  nerves  remaining  intact. 

In  an  unmarried  epileptic  woman  of  twenty-eight 
years  under  my  care,  who  suffered  from  marked 
anemia,  iron  was  the  only  remedy  that  checked  her 
convulsions. 

It  may  be  given  in  the  form  of  the  tincture  per- 
chlorid  in  from  ten-  to  fifteen-minim  doses  three  times 
daily,  or  in  pill  form  as  follows:  Ferric  ferrocyanid 
^  of  a  grain,  extract  of  belladonna  £  of  a  grain,  extract 
of  gelsemium  |  of  a  grain. 


384  THE    MEDICAL    TREATMENT    OF    EPILEPSY. 

I  have  had  uniformly  good  results  from  iron  pepto- 
nate  and  manganese  in  combination  (Pepto-Mangan, 
Gude's)  in  cases  demanding  hemic  reconstruction. 
To  add  small  doses  of  strychnia  nitrate — from  -gL  to  -gV 
of  a  grain — to  each  dose  of  the  Pepto-Mangan  often 
gives  still  more  satisfactory  results. 

The  coal-tar  derivatives,  including  antipyrin,  phen- 
acetin,  and  acetanilid,  especially  the  latter,  for  some 
time  enjoyed  what  I  feel  to  have  been  an  unwarranted 
popularity  in  the  treatment  of  epilepsy.  I  carefully 
tested  the  value  of  each  in  a  large  number  of  cases 
selected  to  meet  the  physiologic  actions  of  the  drug. 
It  could  not  be  ascertained  that  any  of  them  exerted 
any  beneficial  influence  over  the  seizures.  They  were 
occasionally  found  useful  in  allaying  post-convulsive 
headache.  In  epilepsy  as  elsewhere  their  continued 
use  is  inadvisable  on  account  of  the  manner  in  which 
they  affect  the  heart. 

Chloroform. — "  Whatever  opinion  theoretical  writers 
might  have  advanced  on  the  use  of  chloroform  in 
epilepsy,  I  believe  that  few  practical  physicians  after 
having  tried  it  are  willing  to  place  reliance  on  it," 
wrote  Echeverria  a  third  of  a  century  ago. 

After  an  extended  experience  with  the  drug  in  this 
respect,  I  am  of  the  same  opinion.  In  a  few  cases  of 
status  epilepticus  I  have  seen  it  check  the  convulsions ; 
but  I  have  seen  it  more  frequently  fail  to  do  so.  In 
one  case  in  which  the  patient  had  549  seizures  in  two 
days,  profound  chloroform  narcosis  was  kept  up  nine 
hours  altogether,  two  hours  at  one  time,  two  at  another, 
and  five  the  last  time.  All  the  attacks  began  in  the 
right  thumb,  next  involving  the  right  arm,  then  the 
right  leg  and  right  side  of  the  face.  During  the 
chloroform  narcosis  they  did  not  extend  to  the  oppo- 
site side,  otherwise  they  did.  This  was  the  only 
favorable  effect  obtained.  Death  occurred  after  the 
five  hundred  and  forty-ninth  seizure. 


ELECTRICITY.       HYDROTHERAPY.  385 

Moreau  has  stated  that  in  vertiginous  epilepsy 
chloroform  may  prove  fatal  (this  possibly  refers  to 
syncopal  attacks  due  to  heart  disease).  Fox  noted, 
in  using  it  to  detect  simulation,  that  it  increased  the 
attacks  in  three  cases.  Tosquinet*  is  of  the  opinion 
that  it  induces  the  paroxysms.  Echeverria  is  unable 
to  recall  any  epileptic  suffering  from  successive  fits 
who  was  relieved  by  inhalations  of  chloroform  or 
ether. 

Six  patients  presenting  gastric  aura  and  showing 
some  debility  were  selected  at  the  Colony  and  given 
chloroform  and  glycerin  internally  for  several  months ; 
the  former  in  ten-minim,  the  latter  in  one-drachm 
doses,  with  satisfactory  results.  The  attacks  were 
decreased  in  frequency  coincident  with  improvement 
in  the  physical  condition-.  A  very  small  proportion 
of  cases  are  eligible  for  such  treatment.  The  essentials 
for  it  include  a  state  of  general  debility,  and  an  aura 
that  implicates  the  pneumogastric  nerve. 

Electricity  has  been  advocated  in  epilepsy  (Fere, 
Althus,  Fischer),  either  in  the  form  of  galvanization 
of  the  sympathetic  or  of  the  head,  the  current  being 
passed  obliquely  from  the  frontal  region  to  a  point 
diametrically  opposite  at  the  nucha;  or,  as  Althus 
recommends,  transverse  galvanization  of  the  mastoid 
apophyses.     Others  advise  general  faradization. 

In  the  great  majority  of  cases,  the  philosophy  of  such 
treatment  is  no  more  apparent  than  that  of  treating 
epilepsy  with  electric  light  rays  in  a  confined  room,  as 
Hughes  advised.  Direct  applications  of  the  electric 
current  may  indirectly  benefit  epilepsy  in  a  very  small 
number  of  cases  by  benefiting  the  patient's  general 
condition. 

Hydrotherapy  is  beneficial  in  selected  cases.  It  often 
does  good  by  relieving  the  effects  of  bromid  intoxica- 

*  "De  l'inspiration  du  chloroform  comme  moyen  de  constater  l'epilepsie," 
"Archives  Beiges  de  Medecine,"  t.  xn. 


386  THE    MEDICAL    TREATMENT    OF    EPILEPSY. 

tion.  It  can  only  benefit  the  epilepsy  through  the 
favorable  modification  it  induces  in  the  patient's 
general  condition.  The  methodical  tests  made  by 
Fleury  confirmed  this  fact. 

Any  form  of  hydrotherapy  that  renders  more  regular 
and  active  the  peripheral  circulation  will  prove  bene- 
ficial in  epilepsy.  For  details  of  such  measures  the 
reader  is  referred  to  the  last  edition  of  Baruch's 
admirable  work  on  this  subject. 

The  serum  treatment  of  epilepsy  was  carefully  tried 
by  Ceni*  under  methods  elaborated  by  himself. 
Ceni's  experiments  were  based  on  the  opinions  of 
Evans,  Regis,  Chevalier,  Lavause,  Jacobson,  Fere, 
Voisin,  D'Abundo,  Herter,  and  others,  to  the  effect 
that  some  toxic  irritating  cause,  probably  of  a  bio- 
chemic  nature  and  elaborated  by  the  organism,  must 
be  of  capital  import  in  the  determination  of  the  epilep- 
tic fit. 

Ceni  first  tried  to  ascertain  if  epileptic  blood  serum, 
which  was  assumed  to  contain  a  specific  poison,  would 
not  in  time  introduce  into  the  system  some  property 
of  therapeutic  value  in  earlier  and  less  severe  cases. 
The  results  were  not  encouraging.  He  then  tried  to 
render  epileptics  less  resistant  to  the  actions  of  poisons 
circulating  in  them,  through  progressive  doses  of  the 
same  serum — to  establish  immunity. 

Without  going  into  the  details  of  the  results  as  set 
forth  in  Ceni's  paper,  it  may  be  said  that  they  differed 
in  no  essential  respect  from  those  obtained  under 
almost  any  new  method  that  so  jealously  guards  the 
patient's  welfare  in  general  ways  while  it  is  under 
trial. 

The  influence  of  concurrent  diseases  in  epilepsy  has 
often  been  called  to  attention.  It  appears  that 
Hippocrates  spoke  of  it  first  in  connection  with  ma- 
laria. 

*  "Serotherapy  in  Epilepsy,"  Craig  Colony  Prize  Essay,  "Medical 
News,"  March  8  and  15,  1902. 


INFLUENCE    OF    CONCURRENT    DISEASES.  387 

Marandon  de  Montyel  and  Maurice  Dide  *  thor- 
oughly investigated  the  relationship  between  malarial 
infection  and  epilepsy  in  several  cases.  While  they  do 
not  deny  an  apparent  improvement  under  such  an 
infection  in  some  cases,  they  cite  fourteen  instances 
in  which  it  was  followed  by  grave  results.  In  no 
instance  were  they  able  to  say  that  the  epilepsy  dis- 
appeared with  the  appearance  of  malarial  fever.  In 
two  cases  seizures  came  on  coincidently  with  the  rise 
in  temperature ;  in  others,  during  the  intervals  between 
the  malarial  paroxysms. 

These  writers  agree  with  Fere  that  the  chances  for 
improvement  are  too  uncertain  to  warrant  the  utiliza- 
tion of  bacterial  products  in  the  practical  therapeutics 
of  epilepsy,  as  has  been  proposed. 

Bourneville  f  reports  an  epidemic  of  typhoid  fever 
among  children  at  the  Bicetre,  seven  of  them  being 
epileptics.  "All  seizures,"  he  states,  "were  sus- 
pended during  the  attack  of  fever.  This  inhibiting 
effect  persisted  after  recovery,  only  one  or  two  attacks 
having  been  since  noticed  among  them  all."  The 
length  of  time  of  freedom  from  the  attacks  is  not 
given.     Sometimes  typhoid  fever  causes  status. 

Clark  and  Sharp  {  report  five  cases  of  measles  and 
seven  of  erysipelas  occurring  in  epileptics  at  the  Craig 
Colony,  summarizing  their  conclusions  as  to  the  effects 
of  the 'two  diseases  on  epilepsy  as  follows:  "Our  de- 
ductions in  these  cases  are  that  in  not  one  instance  was 
the  pre-existing  epilepsy  favorably  modified  for  any 
great  length  of  time."     (Italics  theirs.) 

In  cases  that  underwent  favorable  modification  it 
was  slight  and  of  short  duration.  It  seemed  clear 
that  the  status  epilepticus  in  one  case  was  due  to  the 
effects  of  the  measles. 

*  "Revue  de  medecine,"  Dec.  io,  1899. 
t  "Progres.  medical,"  Paris,  Sept.  2,  1899. 
X  "Medical  News,"  Dec.  1,  1900. 


388  THE    MEDICAL    TREATMENT    OF    EPILEPSY. 

In  six  patients  under  my  care  who  contracted  diph- 
theria, the  attacks  for  three  months  before  such  illness, 
and  for  a  corresponding  period  after,  were  as  follows : 

Case      I,   19  before,  45  after. 

Case     II,   20       "         19 

Case  III,   19       "  4 

Case   IV,     7  15 

Case     V,  43       "         50 

Case   VI,   25  15 

Ebstein  has  called  attention  to  the  associated 
occurrence  of  diabetes  and  epilepsy,  but  does  not 
attempt  to  explain  any  relationship  there  may  be 
between  them. 

The  Relief  of  Eye-strain  in  Epilepsy. — A  few  ophthal- 
mologists (Gould,  Stevens,  Ranney)  claim  that  the 
relief  of  eye-strain  in  epilepsy  not  infrequently  cures 
the  disease.  Some,  like  Stevens  and  Ranney,  believe 
in  operation  for  the  correction  of  imbalance  of  the 
ocular  muscles;  others,  like  Gould,  think  operation  is 
inadvisable,  and  seek  to  correct  the  trouble  with 
glasses  only. 

I  am  unable  to  recall  a  case  of  epilepsy  in  all  my 
experience  in  which  I  felt  that  defective  ocular  condi- 
tions alone  caused  the  disease.  Several  patients  have 
entered  the  Colony  whose  eye  muscles  had  previously 
been  cut  without  any  improvement  in  their  epilepsy. 

Gould  and  Bennett  made  a  most  careful  scientific 
test  of  the  possible  influence  of  eye-strain  upon  the 
etiology  and  cure  of  epilepsy  at  the  Colony  in  1902. 
I  quote  in  part  from  their  preliminary  report.* 

' '  The  examinations  of  the  eyes  were  begun  on 
August  18,  1902,  and  continued  for  five  days. 

"We  examined  in  all  seventy-eight  patients,  the 
youngest  ten,  the  oldest  fifty-nine  years  of  age,  the 
majority    being    young    or    middle-aged    adults.     Of 

*  "Eye-strain  and  Epilepsy:  A  Preliminary  Report,"  "American  Medi- 
cine," Vol.  iv,  No.  11,  pages  416,  417,  Sept.  13,  1902. 


RELIEF    OF    EYE-STRAIN    IN    EPILEPSY.  389 

these  seventy-eight,  two  were  excluded  because  of 
organic  diseases  of  the  eyes  which  rendered  them 
useless  for  the  purposes  of  the  tests  in  view.  Five 
more  were  excluded  because  of  the  impossibility,  due 
to  psychic  or  ocular  amblyopia,  of  diagnosticating  the 
ametropia.  This  left  seventy-one  cases.  Of  these, 
three  were  excluded  because  the  ametropia  was  of  so 
low  a  degree  that  it  was  thought  negligible.  These 
patients  needed  no  glasses,  either  for  the  relief  of 
ocular  conditions  or  of  reflex  results.  Only  about  4 
per  cent.,  therefore, — three  out  of  seventy-one  cases, — 
seemed  to  us  to  have  eyes  so  near  normality  of  optic 
conditions  that  they  required  no  further  attention. 

"Our  tests,  therefore,  concern  sixty-eight  cases, — 
thirty-five  men  and  thirty-three  women.  These  were 
chosen  for  us  by  the  superintendent  regardless  of  all 
conditions  of  epilepsy,  age,  etc.,  except  that  we  re- 
quested that  only  patients  be  given  us  who  were  sane 
and  who  could  read. 

' '  The  errors  of  refraction  were  estimated  only  after 
thorough  paralysis  of  the  accommodation  by  means  of 
homatropin  and  cocain.  Dr.  Bennett  diagnosticated 
the  muscle-imbalance,  made  the  ophthalmoscopic 
examinations,  and  estimated  the  refractive  errors 
objectively  by  means  of  the  retinoscopic  method.  Dr. 
Gould  made  the  subjective  refraction  and  accommoda- 
tion tests,  and  dictated  the  prescriptions.  The  sub- 
jective tests  were  in  all  cases  those  finally  relied  upon 
when  the  patients'  answers  could  be  trusted,  and  the 
results  seemed  the  more  accurate. 

"The  following  table  of  the  sixty-eight  cases  shows: 


Number  of    Approximate 


ases. 

Per  Cent 

13 

20 

54 

80 

33 

50 

IS 

22 

23 

34 

Myopic  or  compound  myopic  astigmatism. 

Hyperopic  or  compound  hyperopic  astig- 
matism. 

Unsymmetric  astigmatism. 

Normal  acuteness  of  vision  (with  correction). 

Moderately  subnormal  acuteness  of  vision 
(with  correction). 


39°  THE    MEDICAL    TREATMENT    OF    EPILEPSY. 


umber  of 

Approximate 

Cases. 

Per  Cent. 

3° 

44 

f$  vision  or  less  (with  correction). 

3 

Regular  isometric,  compound  astigmatism. 

I 

Simple  regular  astigmatism. 

1 

Simple  hyperopia. 

0 

Simple  myopia. 

9 

Absolutely  isometric,  i.  e.,  about  77  per  cent, 
had  anisometropia. 

"The  muscle -imbalances  for  any  high  or  compli- 
cating significance  were  unexpectedly  absent.  In- 
deed, in  but  one  case  did  we  think  them  worth  con- 
sideration, so  far  as  final  correction  was  concerned. 

"The  astonishing  fact,  and  one  that  we  think  de- 
serves most  serious  attention,  is  the  enormous  pro- 
portion among  these  patients  of  cases  of  injurious 
astigmatic  and  anisometropic  defects;  in  sixty-seven 
out  of  sixty-eight  cases  there  was  astigmatism;  and  it 
is  most  noteworthy  that  about  half  of  the  entire 
number  of  patients  had  unsymmetric  astigmatism,  a 
defect  which  almost  inevitably  produces  the  most 
injurious  results  upon  cerebral  and  assimilative  func- 
tion. This  terrible  incidence  of  unsymmetric  astig- 
matism in  epileptics  is,  we  judge,  twenty  or  more 
times  as  great  as  in  ordinary  patients.  We  do  not  say 
that  these  high  and  most  injurious  ametropic  defects 
caused  the  epilepsies  of  these  patients.  That  can  only 
be  determined  in  the  future  by  the  careful  records  of 
seizures  to  be  kept  and  compared  with  those  of  the 
past.  If  none  of  the  patients  is  cured  by  the  relief 
of  eye-strain  it  would  still  not  disprove  the  theory 
that  in  a  certain  number  the  eye-strain  might  have 
been  the  initial  cause." 

The  sixty-eight  patients  were  carefully  fitted  with 
glasses  by  an  expert  optician,  were  placed  under  the 
care  of .  a  physician  who  saw  them  daily  to  insure 
proper  wearing  of  their  glasses,  and  a  record  was 
kept  of  all  attacks,  day  and  night,  for  a  year  after. 
The  following  table  gives  the  results  in  detail  in  all 
presenting  an  unbroken  record  in  the  period  of  treat- 


RELIEF    OF    EYE-STRAIN    IN    EPILEPSY. 


391 


ment  for  three  months  before  and  three  and  six  months 
after  wearing  glasses. 

The  results   at  the   end   of  the   year  were  not  far 
different  from  those  at  the  end  of  six  months. 


TABLE  SHOWING   RESULTS  OF  RELIEF  OF  EYE-STRAIN  IN 

EPILEPSY. 


Males. 

Females. 

tA    OJ  0 

<"  4)  bztr 

m  ai  v  >A 

«  do 

t  <n  !2  .' 

If]  Ifl  U  ,; 

Attack 
Thre 
rior     t 
lasses. 

Attack 
Thre 
illowin 

ing      c 

Attack 

Month 

th 

Glasse: 

Attack 
Thre 
rior     t 
asses. 

Attack 
Monti 
e  Weai 
s. 

Attack 

Month 

th 

Glasses 

,_  ^O 

—    'J-'. 

•-.*  MO 

_  fcO 

<u  ■-  a; 

*—  *  bl  0 

0     m 

0t/}.=  Sf 

0    M 

<=.=  w« 

0cT;  =  M 

0 

u  W.C-- 

l_  Mi  — 

6 

tt>   b 

.H.=  o 

i_  ofl^.E 

2 

V 
01 

umbe 
duriii 
Mont 
Weai 

umbe 

duriii 

Mont 

the 

Glass 

umbe 
duriii 
Folio 
Weai 

Z 

V 

a 

umbe 
durin 
Mont 
Wear 

umbei 
uring 
'ollow 
ig  of 

umbe 
durin 
Follo; 
Wear 

U 

2 

Z, 

Z 

O 

Z 

z^-= 

Z 

I 

69 

29 

29 

I 

57 

59 

119 

2 

2 

4 

22 

2 

9 

14 

25 

3 

12 

8 

8 

3 

1 

0 

O 

4 

7 

J3 

28 

4 

5 

10 

19 

5 

6 

2 

6 

5 

7 

7 

24 

6 

14 

21 

36 

6 

79 

16 

204 

7 

11 

112 

138 

7 

22 

4 

41 

8 

23 

11 

3i 

8 

1 

1 

3 

9 

23 

8 

19 

9 

0 

0 

0 

10 

0 

9 

9 

10 

0 

0 

0 

11 

0 

1 

3 

11 

0 

3 

9 

12 

3 

3 

7 

12 

202 

!°5 

344 

13 

9 

16 

20 

13 

14 

14 

17 

14 

6 

4 

11 

14 

0 

0 

0 

J5 

0 

0 

0 

15 

4 

10 

14 

16 

4 

1 

3 

16 

36 

42 

73 

17 

3 

4 

8 

17 

6 

0 

7 

18 

306 

222 

400 

18 

0 

0 

0 

19 

0 

0 

0 

19 

17 

23 

36 

20 

24 

24 

43 

20 

7 

4 

8 

21 

3 

3* 

3 

21 

1 

3* 

0 

22 

33 

33 

5° 

22 

26 

32 

64 

23 

11 

3 

23 

23 

48 

59 

89 

24 

24 

14 

29 

24 

5° 

59 

83 

25 

35 

32 

35 

25 

22 

14 

24 

26 

74 

85 

185 

26 

17 

5° 

99 

27 

2 

6* 

6 

27 

1 

6 

12 

28 

4 

10 

17 

28 

12 

21 

40 

29 

33 

56 

107 

29 

3 

2 

6 

30 

0 

0 

6 

30 

2 

8 

17 

31 

25 

3i 

5° 

3i 

7 

11 

17 

32 

2 

2 

3 

33 

12 

J3 

29 

Total 

766 

765 

J332 

Total 

670 

592 

1426 

*  These  cases  passed  from  under  observation  at  the  end  of  the  first  three 
months'  period. 


392         THE    MEDICAL   TREATMENT    OF    EPILEPSY. 

The  results  of  this  experiment  so  carefully  made  were 
not  encouraging.  The  nearest  approach  to  a  cure  was 
in  case  No.  Ill  (male).  This  patient  had  no  attacks 
in  June,  eight  in  July,  and  four  in  August,  the  three 
months  preceding  the  use  of  glasses.  He  began  to  wear 
them  September  i,  1902,  and  had  eight  attacks  in  the 
next  twelve  months,  four  in  September  and  four  in  Octo- 
ber, 1902.  His  attacks  were  grand  mat,  always  severe, 
and  universally  began  with  a  bilateral  arm  aura,  both 
hands  finally  being  jerked  above  the  head  some  time 
before  the  fit.* 

Some  patients  (four  or  five)  declared  that  the  use 
of  glasses  had  benefited  them  in  some  way,  mostly  in 
the  relief  of  headache. 

The  totals  show  that  the  thirty-one  males  had  766 
seizures  during  the  three  months  prior  to  the  wearing 
of  glasses,  765  during  the  first  three  months  after,  and 
1332  during  the  first  six  months  after;  that  the  thirty- 
three  females  had  during  three  similar  periods,  670, 
592,  and  1426  seizures. 

*  After  going  14  months  without  an  attack,  they  recurred  in  January, 
1904,  as  severe  as  ever. 


CHAPTER  XV. 
THE  SURGICAL  TREATMENT  OF  EPILEPSY. 

Types  of  Epilepsy  Suitable  for  Surgical  Intervention.  Jacksonian  and 
Grand  Mai,  Idiopathic,  Organic,  Traumatic.  Clinico-pathologic  Guides 
to  Operation.  Technique  of  Trephining.  Technique  of  Abdominal  Sec- 
tion with  Indications  for  the  Performance  of  Each.     Results. 

The  presence  of  epilepsy  being  established,  there  are 
two  essential  preliminaries  to  be  observed  before  under- 
taking any  operation  upon  the  brain  for  its  possible 
relief : 

i.  The  determination  of  its  type  and  cause. 

2.  The  determination  of  the  point  on  the  cranium 
at  which  the  operation  is  to  be  performed. 

Both  embrace  questions  of  the  utmost  importance, 
the  determination  of  which  rests  with  the  physician 
before  the  surgeon  can  be  called  upon  to  operate. 

In  some  forms  of  epilepsy  surgical  intervention  is 
permissible,  often  valuable,  less  often  curative;  but  in 
others  it  is  wholly  unjustifiable. 

At  the  outset  we  exclude  from  surgical  consideration, 
so  far  as  operations  on  the  brain  are  concerned,  petit 
mal,  psychic,  hystero-epilepsy,  serial  attacks,  and 
status.  Rarely  we  may  find  accidental  and  isolated 
occasions  for  operating  on  some  of  these,  but  even  so, 
the  principles  and  methods  applicable  in  other  types 
apply  fully  as  well  as  in  these. 

The  surgical  treatment  of  pseudo-epileptic  convul- 
sions that  follow  peripheral  irritations  will  be  men- 
tioned later. 

Excluding  the  inoperable  ones  enumerated  above, 
we  have  but  two  varieties  left  for  possible  surgical 
treatment,  and  these  are  grand  mal  and  Jacksonian 

393 


394         THE    SURGICAL    TREATMENT    OF    EPILEPSY. 

epilepsy.  The  latter,  as  we  have  already  seen,  appears 
as  a  distinct  affection  under  one  form,  impossible 
ordinarily  of  being  mistaken  for  any  other.  The 
former  is  encountered  from  an  etiologic  standpoint 
under  three  types, — idiopathic,  organic,  and  trau- 
matic. 

Traumatic  grand  mal  epilepsy  comes  more  often  to 
the  operating  table  than  any  other  type  of  the  disease. 
We  have  previously  noted  that  in  814  male  and  509 
female  epileptics  carefully  studied,  trauma  was  the 
ascribed  cause  in  8^  per  cent,  of  the  former  and  3$ 
per  cent,  of  the  latter.  Male  epileptics  far  more  often 
than  female  epileptics  are  therefore  candidates  for 
surgical  intervention.  It  was  also  observed  that  in 
seventy-three  out  of  eighty-eight  cases  in  both  sexes 
the  trauma  was  received  before  the  twentieth  year; 
while  reference  was  likewise  made  to  the  manner  in 
which  such  injuries  were  most  frequently  received. 

It  cannot  be  said  that  the  trauma  was  the  sole 
cause  of  the  epilepsy  in  all  cases,  but  it  was  unques- 
tionably a  contributing  factor  when  it  did  not  act 
alone. 

The  type  of  cases  in  which  surgery  most  often  fails 
to  give  satisfactory  results,  even  when  it  is  done  at 
the  proper  time,  i.  e.,  immediately  after  the  receipt  of 
the  injury,  are  those  in  which  the  injury  was  a  part 
of  the  cause  only,  often  the  minor  part,  the  chief 
cause  lying  in  the  patient's  strong  epileptic  predispo- 
sition. In  many  such  cases  the  epileptic  state  is 
divided  from  the  non-epileptic  state  by  a  thin  parti- 
tion which  the  injury  destroys  and  which  no  operation 
can  restore.  It  is  essential  that  we  understand  this 
fact  before  operation  is  undertaken.  If  it  is  optional 
with  us  to  operate  or  not  in  cases  of  unfavorable 
heredity,  it  is  generally  better  to  err  on  the  side  of 
refusal  than  to  proceed  in  the  face  of  such  an  obstacle 
and  expect  good  results  to  follow.     This  is  true  as  a 


CLINICO-PATHOLOGIC  GUIDES  TO  OPERATION.       395 

general  condition ;  in  exceptionally  rare  instances  oper- 
ation may  be  justifiable,  no  matter  how  unfavorable 
the  patient's  family  history  may  be. 

We  have  elsewhere  noted  (Prognosis)  the  good 
results  that  often  follow  medical  treatment  in  the 
worst  hereditary  cases.  The  same  principles  are 
applicable  here,  namely,  the  disease  being  so  largely 
due  to  heredity  and  so  likely  to  follow  minor  indis- 
cretions, the  patient  is  doubly  careful  to  guard  against 
the  infinity  of  irregularities  that  often  bring  the 
paroxysms  to  light.  On  the  other  hand,  one  must  not 
forget  that  the  after-treatment  of  surgical  cases  has 
been  growing  in  importance  of  late  years,  and  that 
an  operation  often  serves  to  enhance  the  opportunity 
for  the  more  effective  usage  of  the  former. 

Roswell  Park  very  aptly  set  forth  this  point  when 
he  said:  "Operation,  when  indicated  and  undertaken, 
should  be  regarded  as  a  first  measure  to  be  followed 
and  often  preceded  by  others  looking  to  a  correction 
of  all  faults  of  diet,  elimination,  etc.  Long-continued 
attention  to  these  matters  is  the  price  of  suc- 
cess." 

CLINICO-PATHOLOGIC  GUIDES  TO  OPERATION. 

If  the  epilepsy  is  supposedly  due  to  trauma  we  first 
look  for  scars  on  the  cranium.  These  may  be  of  the 
scalp  only  and  show  no  evidence,  such  as  depression, 
tenderness  on  pressure,  etc.,  of  fracture  of  the  skull. 
They  are  most  often  found  over  the  motor  areas.  "As 
convulsions  play  so  minor  a  role  in  the  acute  symptoms 
of  fractures  at  the  base,  we  would  hardly  expect  epi- 
lepsy to  be  a  consequence  of  that  injury,  and  it  does 
not  seem  to  be  one.  In  826  cases  at  the  Craig  Colony 
for  Epileptics  there  was  only  one  in  which  there  was 
any  suggestion  of  a  fracture  at  the  base."* 

*  Pearce  Bailey,  "Fracture  at  the  Base  of  the  Skull,  Neurological  and 
Medicolegal  Considerations,"  "New  York  Medical  Record,"  May  16,  1903. 


396         THE    SURGICAL    TREATMENT    OF    EPILEPSY. 

As  a  rule,  the  epilepsies  that  follow  injury  to  the 
frontal  lobes  demand  early  treatment  for  good  results. 
When  neglected,  they  produce  early  mental  death. 
The  absence  of  depression  at  the  site  of  the  scar  does 
not  preclude  the  possibility  of  fracture.  There  may 
also  be  subdural  or  epidural  hemorrhage  without 
fracture,  either  causing  epileptiform  convulsions  that  in 
time  may  pass,  so  far  as  results  are  concerned  at  least, 
into  the  true  disease.  Organic  epilepsies  of  this  kind 
either  come  on  just  after  the  injury  or  they  may  be 
delayed  some  time,  the  patient  passing  in  the  meanwhile 
through  a  serious  illness,  having  "brain  fever,"  some 
degree  of  paralysis  which  corresponds  with  the  site 
of  the  clot  or  injury,  a  high  temperature,  great  pros- 
tration, delirium,  and  often  a  series  of  acute  convul- 
sions that  may  be  so  severe  and  so  frequently  repeated 
as  to  run  into  status. 

The  sooner  the  operation  is  performed  in  these 
cases,  the  more  hopeful  the  prognosis  of  recovery. 
As  a  rule,  good  recoveries  are  made  from  the  operation 
when  the  patient's  stamina  is  good  and  when  he  does 
not  represent  an  epileptic  ancestry.* 

"A  student,"  reports  Keen,t  "was  injured  in  a 
football  game.  When  I  first  saw  him,  three  days  after 
the  accident,  I  found  that  he  had  been  unconscious 
for  a  half  hour  after  the  accident,  and  ever  since  then 
had  complained  bitterly  of  headache  which  he  located 
always  in  the  forehead.  Mentally  he  was  very  dull, 
though  not  comatose.  His  pulse  was  slowed  down  to 
52  instead  of  72,  the  normal.  Soon  after  the  accident 
he  began  to  develop  convulsions,  first  in  the  right  leg. 
afterward  in  the  right  arm  also,  the  right  arm  being 

*  In  speaking  of  such  cases,  we  have  especially  in  mind  the  great  im- 
portance of  early  treatment  to  prevent  the  patients  from  becoming  true 
epileptics.  Recent  convulsions  due  to  trauma  do  not  belong  to  the  class 
of  essential  epileptics. 

t  "Philadelphia  Medical  Record,"  Dec.  13,  1902. 


CLINICO-PATHOLOGIC  GUIDES  TO  OPERATION.       397 

finally  the  chief  seat  of  the  convulsions.  When  they 
were  severe,  they  involved  the  left  side  also.  The 
face  was  never  involved. 

"In  six  hours  and  a  half  after  I  first  saw  him  lie 
had  twenty-four  of  these  attacks,  all  limited  to  the 
right  arm.  (This  is  a  clear  illustration  of  Jacksonian 
epilepsy,  needing  only  the  more  permanent  establish- 
ment of  the  localized  convulsive  attacks.  The  author.) 
They  were  not  attended  with  any  loss  of  consciousness. 
They  exhausted  him  very  greatly,  especially  when  they 
were  excessively  severe.  Several  times  it  was  neces- 
sary to  give  him  chloroform. 

"There  was  no  fracture  of  the  skull.  The  only 
physical  evidence  of  any  injury  was  a  very  slight 
bruise  at  the  outer  end  of  the  left  eyebrow.  Had  I 
seen  this  patient  before  1885,  I  should  have  been  unable 
to  explain  why  the  spasms  were  chiefly  manifested 
in  the  right  arm,  and  from  the  headache,  the  stupor, 
the  bruise  on  the  left  temple,  I  should  have  been 
justified  in  inferring  that  probably  the  front  part  of 
the  brain  was  injured  at  the  site  of  the  bruise.  Had 
I  opened  the  skull  at  that  point,  I  should  have  found 
a  perfectly  normal  brain  and  should  have  missed  the 
clot.  The  young  man,  therefore,  would  have  died 
whether  his  skull  was  opened  or  not. 

"  In  1902  observe  the  difference.  As  a  result  of  the 
knowledge  derived  from  experiments  upon  animals, 
which  have  located  precisely  the  center  for  motion  of 
the  right  arm  on  the  left  side  of  the  brain  near  the  top 
and  a  little  in  front  of  a  vertical  line  drawn  through 
the  ear,  and  disregarding  entirely  the  site  of  the  head- 
ache and  the  bruise,  I  reached  the  conclusion  that 
there  had  been  a  rupture  of  a  blood-vessel  within  the 
head  which  had  poured  out  a  quantity  of  blood  and 
that  the  situation  of  the  clot  should  correspond  to  the 
'arm  center.'  The  location  of  this  arm  center  was  far 
away  (about  three  inches)   from  the  location  of  the 


398         THE    SURGICAL    TREATMENT    OF    EPILEPSY. 

braise,  and  its  position  was  fixed  absolutely  as  a  result 
of  experiments  upon  animals,  confirmed  later  by  many 
operations  on  human  beings,  and  also  by  postmortems. 
"As  soon  as  the  skull  was  opened  at  this  point,  the 
clot  was  found,  its  thickest  point  being  exactly  over 
the  arm  center,  and  nine  tablespoonfuls  of  blood  were 
removed,  with  the  result  that  the  patient's  life  was 
saved.  The  blood  had  first  been  poured  out  over  the 
'leg  center,'  which  is  located  higher  up  than  that  for 
the  arm.  This  explained  the  long  spasms  in  the  right 
leg.  The  clot  did  not  extend,  however,  further  down 
than  the  arm  center.  This  explained  why  the  face 
was  never  convulsed,  for  the  face  center  lies  just  below 

that   for  the   arm The  patient   made   a 

complete  recovery." 

THE  POINT  OF  OPERATION. 

The  physician  who  undertakes  to  map  out  the  site 
for  the  operation  of  trephining  in  epilepsy  must 
possess  not  only  a  definite  knowledge  of  the  great 
variety  of  epileptic  aura,  but  he  must  know  the  im- 
portant facts  of  cerebral  localization  as  well.  These 
two  things  constitute  the  supreme  guides  at  our  com- 
mand. If  the  convulsions  are  foreshadowed  by 
numbness  and  twitching  in  the  hand,  or  by  convul- 
sive movements  in  the  leg  or  foot  or  side  of  the  face, 
or  by  some  disturbance  of  vision,  hearing,  taste,  or 
smell,  or  by  any  distinct  localizing  symptoms,  we 
must  follow  these  initial  manifestations  back  to  their 
probable  point  of  origin  and  be  able  to  locate  the  area 
in  the  brain  from  which  they  came. 

There  is  no  other  disease  in  which  a  thorough  knowl- 
edge of  cerebral  localization  is  so  important  and  none 
in  which  the  guides  to  location  are  so  clear  and  specific 
as  furnished  by  the  aura  in  epilepsy  when  fully  studied 
and  properly  interpreted. 

When  cases  are  met  with  in  which  the  localizing 


THE    POINT    OF    OPERATION.  399 

symptoms  do  not  correspond  to  the  site  of  the  injury, 
it  is  best  to  follow  the  medical  indication,  operating 
at  the  point  which  should  give  rise  to  such  symptoms 
and  not  at  the  point  of  injury. 

Traumatic  epilepsy  is  often  indefinite  in  its  expres- 
sion ;  that  is,  a  local  injury  does  not  always  produce  a 
local  fit;  or  again  the  fit  may  be  confined  to  certain 
parts  for  months,  and  then,  without  known  cause, 
become  general.  This  tendency  probably  represents 
the  worst  phase  of  the  affection;  it  means  a  more 
widespread  implication  of  brain  tissue  in  the  process 
of  degeneration,  a  lessened  power  of  resistance  under 
repeated  attacks.  If  the  patient  is  naturally  prone 
to  disease,  this  retrogression  will  appear  all  the  quicker, 
so  that  the  cardinal  rule  in  every  surgically  treated 
case  of  epilepsy  should  be,  operate  as  soon  after  the 
receipt  of  the  injury  as  possible:  never  let  a  second  con- 
vulsion follow  the  first  when  due  to  injury,  if  it  can  be 
prevented  by  surgical  intervention. 

Trephining  in  idiopathic  epilepsy  is  sometimes  done 
under  the  assumption  that  the  convulsions  are  due 
to  increased  intracranial  tension.  Kocher,  in  Switzer- 
land, and  several  American  surgeons  did  this  operation 
quite  extensively  a  few  years  ago;  at  present  it  has 
almost  fallen  entirely  into  disuse. 

It  is  far  more  rational  to  operate  in  idiopathic  cases 
with  localizing  symptoms  than  in  idiopathic  cases 
without  such  symptoms,  even  though  the  results  under 
the  former  up  to  this  time  have  been  disappointing. 

A  distinctly  localizing  symptom  does  not  always 
mean  a  localized  condition  or  disease  susceptible  of 
removal  by  the  knife.  The  fact  has  repeatedly  been 
made  patent  to  us.  The  woman  previously  mentioned 
who  had  519  seizures  in  forty-nine  hours  and  a  half, 
the  initial  contraction  each  time  being  confined  to  the 
first  phalanx  of  the  right  thumb,  upon  whom  an  autopsy 
was  performed  at  the  end  of  that  time,  and  whose 


400         THE    SURGICAL    TREATMENT    OF    EPILEPSY. 

brain  showed  (under  careful  pathologic  study)  abso- 
lutely no  trace  of  local  disease  save  a  condition  of 
cell-vacuolation,  present  as  a  result  and  in  no  wise  a 
cause,  is  a  typical  case  in  point. 

We  could  mention  others  in  which  the  attacks  con- 
fined to  one  part  of  the  body  for  years  disappeared 
temporarily  upon  the  excision  of  the  corresponding 
brain  center  only  to  recur  in  the  same  site  later  on. 
A  girl  of  thirteen,  an  epileptic  for  six  years,  whose  at- 
tacks averaged  from  seven  to  ten  daily,  nearly  all  begin- 
ning in  the  left  hand,  suffered  excision  of  the  left  hand 
center.  All  power  was  lost  in  the  hand  for  several 
weeks.  Five  days  after  the  operation  the  attacks 
recurred,  but  were  general  in  character.  With  the 
return  of  power  in  the  left  hand  the  attacks  again  began 
in  that  member. 

Repeated  observations  in  cases  like  these  strengthen 
the  belief  that  epilepsy  is  oftener  due  to  widespread 
cortical  conditions  or  disease  than  to  any  circum- 
scribed agent  removable  by  the  knife.  When  localiz- 
ing symptoms  occur  in  such  cases,  they  indicate  the 
weakest  point  in  the  brain  area  diseased,  the  excision 
of  which  necessarily  fails  to  affect  the  larger  fault. 

The  organic  epilepsies  arise  from  such  causes  as 
tumor  of  the  brain,  including  tubercle,  syphiloma, 
glioma,  sarcoma,  and  others  of  less  frequency  such  as 
myxoma,  fibroma,  carcinoma,  osteoma,  lipoma,  psam- 
moma;  in  fact  all  forms  of  new  growths  found  else- 
where may  cause  convulsive  phenomena  by  appearing 
in  the  brain.  Faults  in  the  vascular  system,  hemor- 
rhage, profuse  or  capillary,  emboli,  thrombi,  and 
aneurysms  are  also  occasional  causes. 

It  is  often  a  matter  of  great  difficulty  to  diagnosticate 
brain  tumors  in  epilepsy,  either  as  a  cause  or  as  a 
concurrent  affection,  for  the  reason  that  the  two  dis- 
eases often  produce  almost  identical  symptoms. 

The  only  class  of  epileptics  in  which  the  diagnosis 


THE    POINT    OF    OPERATION.  401 

can  be  made  with  any  degree  of  certainty  is  that  in 
which  the  disease  is  recent,  with  the  mind  but  little 
impaired,  and  with  paroxysms  far  enough  apart  to 
give  the  patient  opportunity  for  reaching  his  normal 
state  between  attacks. 

Tumors  of  the  brain  in  epilepsy  must  therefore  be 
diagnosticated  during  the  inter-paroxysmal  period 
when  the  symptoms  of  tumor  are  not  overshadowed 
by  the  symptoms  of  epilepsy,  such  as  headache,  paral- 
ysis, defective  vision,  and  the  like. 

The  proportion  of  operable  cases  of  brain  tumor 
is  exceedingly  small.  According  to  White  and  Starr, 
only  2  per  cent,  of  them  justify  surgical  measures. 
Bergman  and  Kroenlein  conclude  that  the  indications 
for  operation  in  such  cases  are  very  limited. 

With  the  x-rays  and  with  our  advancing  knowledge 
of  cerebral  localization,  together  with  the  advances  of 
modern  surgery,  we  may  be  led  to  a  point  where  the 
prognosis  under  such  conditions  will  be  more  favorable 
than  it  is  at  the  present  time.  Certain  it  is  that  the 
most  momentous  fact  in  the  entire  domain  of  the 
surgical  treatment  of  the  disease  lies  in  the  early 
recognition  of  the  cause,  and  in  this  the  x-rays  seem  now 
to  promise  aid  in  some  cases. 

Peripheral  Operations. — The  causes  of  epileptiform 
convulsions  that  are  often  amenable  to  surgical  treat- 
ment include  numerous  injuries  and  diseases  in  various 
parts  of  the  periphery.  Thus,  when  a  trauma  involving 
a  nerve  trunk  has  started  the  convulsions,  we  may  try 
revulsives,  then  denudation  of  the  nerve,  stretching, 
or  section  if  necessary.  It  is  a  good  rule  to  resort  to 
local  measures  in  cases  of  this  kind  first,  and  in  a 
majority  of  cases  they  will  be  found  effective,  provided 
the  convulsions  are  not  of  too  long  standing. 

Sometimes  (Fere)  insignificant  irritations  involving 
the  terminal  extremities  ofja  nerve  may  be  the  cause 
of  all  the  trouble,  and  their  removal  may  effect  a 
26 


402         THE    SURGICAL    TREATMENT    OF    EPILEPSY. 

cure.  The  same  is  occasionally  true  in  regard  to 
foreign  bodies  in  the  ear  or  the  nasal  fossa.  Naso- 
pharyngeal polypi  on  removal  have  caused  the  disap- 
pearance of  epileptiform  crises.  Fere  speaks  of  the 
cure  of  auricular  epilepsy  (vertiginous  attacks)  by  re- 
lieving the  Eustachian  tube  of  temporary  obstruction 
by  insufflations  of  air.  The  relief  of  stricture  of  the 
urethra,  an  inherent  prepuce,  and  other  conditions  in 
connection  with  the  reproductive  organs  which  re- 
quire surgical  correction,  sometimes  check  reflex  con- 
vulsive phenomena. 

The  relief  of  eye-strain  as  a  possible  cure  of  epilepsy 
is  fully  discussed  under  the  general  treatment  of  the 
disease  in  the  preceding  chapter. 

Mention  may  be  made  of  such  other  surgical  meas- 
ures as  counter-irritation,  ligature  of  the  vertebral 
arteries,  and  resection  of  the  cervical  sympathetic. 
Under  the  former  a  seton  is  usually  put  in  the  back 
of  the  neck.  "That  this  does  occasional  good  is  tes- 
tified by  strong  though  ancient  evidence"  (Gowers). 
This  writer,  however,  failed  to  secure  any  good  results 
from  its  use.  Accidental  burns  that  cover  large  areas 
are  said  to  produce  results  similar  to  those  from  the 
use  of  the  seton.  We  fail  to  understand  the  value  of 
counter-irritation  as  ordinarily  applied  in  the  treatment 
of  epilepsy. 

Alexander,  of  Liverpool,  was  apparently  the  first 
to  recommend  and  try  ligature  of  both  cerebral  arteries. 
At  best  it  was  an  ill-conceived  procedure  and  is  no 
longer  thought  of. 

Janesco  *  appears  to  have  revived  the  plan  of  com- 
plete bilateral  resection  of  the  cervical  sympathetic 
as  a  possible  cure  of  epilepsy.  He  treated  three 
patients  in  this  way.  Improvement  followed  in  them 
all  for  the  first  five  months,  in  none  did  convulsions 
recur  in  that  time,  while  infrequent    and    transitory 

*  "  Centralblatt  fur  Chirurgie,"  Jan.  16,  1897. 


RESULTS    OF    SURGICAL    INTERVENTION.  403 

attacks  of  vertigo  appeared  in  but  one.  Janesco  con- 
cludes that  total  bilateral  resection  of  the  cervical 
sympathetic  may  be  practised  without  secondary  evil 
results,  and  that  the  operation  is  worthy  of  further 
trial,  basing  the  belief  on  the  demonstrated  disturb- 
ance of  the  cerebral  circulation  during  attacks. 

Carl  Beck  *  reports  three  cases  in  which  he  per- 
formed resection  of  the  sympathetic  ganglia  of  the 
neck,  all  being  cases  of  "genuine  epilepsy"  of  long 
standing.  A  decrease  in  the  frequency  and  severity  of 
attacks  occurred  in  all  cases,  but  gradually  the  old 
condition  returned. 

Roswell  Park  performed  this  operation  on  three 
patients  at  the  Craig  Colony,  and  while  sufficient  time 
has  not  elapsed  to  note  permanent  results,  improve- 
ment was  noted  in  some  respects  immediately  after. 

RESULTS  OF  SURGICAL  INTERVENTION  GENERALLY. 
It  is  exceedingly  difficult  to  sum  up  the  results  of 
the  surgical  treatment  of  epilepsy  for  two  reasons : 

1 .  Those  who  report  cases  commonly  base  their  con- 
clusions on  personal  conceptions  as  to  what  constitutes 
genuine  epilepsy  and  what  does  not.  This  is  bound 
to  be  inevitable  in  the  absence  of  any  fixed  nomencla- 
ture based  on  a  more  scientific  foundation  than  that 
of  symptomatology.  One  operator  or  reporter  may 
regard  epileptiform  convulsions  as  essential  epilepsy, 
while  another  may  look  upon  some  irregular  form  of 
the  latter  as  being  epileptiform  in  character. 

2.  The  lack  of  any  limit  fixed  by  rule  or  common 
consent  as  to  the  period  of  time  that  should  elapse 
after  the  operation  and  before  results  are  announced, 
is  a  second  fruitful  cause  for  misleading  and  imperfect 
statistics. 

A  few  years  ago  the  tendency  to  report  results 
almost    immediately     ("before    the    wound    heals," 

*  "Chicago  Medical  Recorder,"  April,  1899. 


404         THE    SURGICAL    TREATMENT    OF    EPILEPSY. 

Bergman  rather  caustically  remarks)  was  greater  than 
now.  Happily  more  conservatism  is  beginning  to  be 
manifested  in  this  respect. 

It  would  be  unscientific  to  attempt  to  lay  down  any 
rule  as  to  time  for  reporting  results  after  operation, 
applicable  to  all  cases  alike.  Recent  convulsions  in 
distinctly  traumatic  cases  give  definite  results  before 
cases  classed  as  idiopathic  and  of  long  standing.  The 
same  principle,  in  fact,  applies  here  that  is  so  important 
throughout  the  whole  field  of  the  study  of  epilepsy 
and  its  treatment,  namely:  everything  must  be  deter- 
mined upon  an  individual  basis — generalizations  are 
too  often  misleading. 

A  third  stumbling  block  that  the  surgical  treatment 
of  epilepsy  has  frequently  to  encounter  is  that  of 
delay  after  the  receipt  of  the  injury  before  operation 
is  undertaken.  The  time  to  operate  is  at  once,  before 
the  seal  of  chronicity  is  set  beyond  the  possibility  of 
removal.  The  more  marked  the  indications  of  heredity 
as  a  factor  in  causing  the  disease,  the  closer  the  opera- 
tion should  follow  the  trauma,  for  the  disease  in  such 
cases  very  soon  becomes  ineradicable. 

While  the  literature  is  replete  with  the  results  of 
surgical  intervention  in  epilepsy,  the  following  cases 
briefly  cited  from  the  Craig  Colony  records  fairly 
illustrate  the  value  of  this  form  of  treatment : 

Case  I. — A  man  aged  twenty-nine  years.  Family 
history  negative.  Epilepsy  began  at  seventeen  years ; 
supposed  cause,  malaria.  Type,  grand  mal,  idiopathic. 
Trephined  in  October,  1895,  six  years  after  the  first 
seizure.     Results,  negative. 

Case  II. — A  man  aged  thirty-one  years.  Father, 
tuberculous;  family  history  otherwise  negative.  Epi- 
lepsy began  at  twelve  years.  Supposed  cause,  trauma 
to  the  head.  Trephined  over  the  right  motor  region 
in  August,  1894,  eleven  years  after  the  origin  of  the 
epilepsy.     Results,    negative. 

Case  III. — A  young  man  aged  twenty-two  years. 


RESULTS    OF    SURGICAL    INTERVENTION.  405 

Family  history  negative.  Epilepsy  began  at  fifteen 
years.  No  assigned  cause.  The  patient  grew  rapidly 
worse  from  the  outset,  soon  having  as  many  as  twenty- 
four  attacks  in  a  day.  Type,  grand  mal.  Trephined 
in  October,  1897,  three  years  after  the  first  fit.  Fol- 
lowing the  operation  the  attacks  became  fewer  in  fre- 
quency, but  more  severe  in  character.  Trephined  a 
second  time  at  the  Colony  in  April,  1900.  The  attacks 
were  growing  steadily  worse.  A  portion  of  thickened 
and  adherent  dura  was  removed.  Following  the  second 
operation,  the  patient  showed  decided  improvement, 
due  probably  as  much  to  careful  dieting,  nursing,  and 
treatment  in  other  respects,  as  to  the  operation  per  se. 
Results,  great  decrease  in  frequency  and  severity  of 
attacks. 

Case  IV. — A  man  aged  thirty-one  years.  Maternal 
grandfather,  syphilitic  and  insane.  Maternal  aunt, 
insane  and  a  suicide.  One  brother  and  one  sister 
died  in  convulsions.  Paternal  relative,  intemperate. 
Epilepsy  began  at  seventeen  years.  Type,  grand  mal. 
Supposed  cause,  cranial  trauma  at  seven  years.  Tre- 
phined in  1895,  eight  years  after  the  onset  of  epilepsy. 
Results,  negative. 

Case  V. — A  man  aged  thirty-eight  years.  Maternal 
grandmother,  epileptic.  Assigned  cause,  heredity. 
Type,  grand  mal.  Trephined  over  the  left  motor  re- 
gion in  1893,  fifteen  years  after  the  onset  of  epilepsy. 
Result,  slight  temporary  improvement. 

Case  VI. — A  boy  aged  eight  years.  Family  history 
negative.  Epilepsy  began  at  three  years.  Supposed 
cause,  trauma  to  the  head  from  a  fall.  First  attack 
two  months  after  the  fall.  Attacks  increased  in  fre- 
quency so  that  at  the  age  of  five  years  the  patient 
was  having  fifty  a  day.  Two  years  after  the  first 
convulsion  he  was  trephined  over  the  right  motor 
region.  Following  the  operation  he  had  no  attacks 
for  three  years  during  the  day,  but  occurred  during 
the  night  just  the  same.  Result,  decrease  in  number 
of  attacks. 

Case  VII. — A  man  aged  thirty  years.  Mother, 
rheumatic;  father,  inebriate  and  died  of  tuberculosis. 
Epilepsy  began  at  twenty-one  years.  Assigned  cause, 
injury  to  the  left  side  of  head  by  being  run  over  by  a 


406         THE    SURGICAL    TREATMENT    OF    EPILEPSY. 

wagon.  First  convulsion  two  weeks  after  the  accident. 
Attacks  at  first,  three  or  four  daily.  Type,  traumatic 
grand  mal.  Trephined  one  week  after  the  first  attack. 
After  the  operation  he  had  an  average  of  twenty  each 
month.     Result,  slight  decrease  in  number  of  attacks. 

Case  VIII. — A  young  man  aged  nineteen  years. 
Family  history  negative.  Epilepsy  began  at  eleven 
years  as  the  result  of  a  blow  on  the  head  with  a  bale 
stick.  First  convulsion  occurred  half  an  hour  after 
the  injury ;  the  second  a  month  later,  after  which  they 
occurred  with  increasing  frequency.  Trephined  in 
1896,  three  years  after  the  injury.  No  benefit  as  a 
result  of  the  operation.  He  was  trephined  a  second 
time  at  the  Colony  in  April,  1900,  this  time  over  the 
left  motor  region,  this  being  the  site  of  the  injury. 
Nothing  of  a  pathologic  nature  was  found.  Type, 
grand  mal.     Result,  no  improvement. 

Case  IX. — A  man  aged  thirty  years.  Family  history 
negative.  Epilepsy  began  at  seven  years;  supposed 
injury  to  the  head  at  the  third  year.  Trephined  in 
February,  1899,  sixteen  years  after  the  injury  which 
was  supposed  to  have  caused  his  epilepsy.  At  first 
all  his  attacks  were  psychic;  later  they  changed  to 
grand  mal  and  were  not  benefited  by  the  operation. 
Result,  no  improvement. 

Case  X. — A  young  man  aged  twenty  years.  Mother 
and  maternal  grandmother  died  of  tuberculosis. 
Epilepsy  developed  at  twelve  years.  Assigned  cause, 
penetrating  wound  of  the  skull  by  a  nail  when  eight 
years  old.  First  trephined  over  the  left  motor  area 
in  1899,  four  years  after  the  injury.  Trephined  again 
at  the  Craig  Colony  in  November,  1900,  over  the  same 
area.  Thickened  dura  removed  and  gold  foil  inserted. 
Result,  no  improvement. 

Case  XI. — A  man  aged  thirty-six  years.  Father, 
alcoholic.  Maternal  uncle  and  aunt,  insane.  Mother 
and  grandmother  had  organic  heart  disease.  Epilepsy 
began  at  twenty-four  years.  Supposed  cause,  trauma 
to  the  head  a  year  previously.  The  patient  claims  to 
have  received  a  fracture  of  the  skull  at  that  time  by 
falling  from  a  ladder.  First  convulsion  occurred  twelve 
hours  after  the  accident.  Attacks  after  that  occurred 
every  six  weeks.     Eleven  months  later  he  was  tre- 


RESULTS    OF    SURGICAL    INTERVENTION.  407 

phined  over  the  left  frontal  region  in  the  Presbyterian 
Hospital,  New  York.  Six  weeks  after  the  operation  a 
convulsion  occurred.  Shortly  afterward  he  was  given 
large  doses  of  bromid.  Result,  improvement;  no  at- 
tack for  six  months  after  the  operation. 

Case  XII. — A  boy  aged  eleven  years.  Mother, 
neurotic.  Maternal  grandmother  had  two  strokes  of 
paralysis.  Epilepsy  began  at  eight  years,  caused  by 
falling  from  a  shed  a  distance  of  eight  feet,  striking  on 
the  right  side  of  head.  Had  a  convulsion  the  same 
day  of  the  accident.  In  April,  1900,  two  years  after 
the  injury,  he  was  trephined  over  the  right  motor  area 
at  the  site  of  the  injury.     Result,  no  improvement. 

Case  XIII. — A  man  aged  thirty-one  years.  Family 
history  unknown.  Epilepsy  began  at  nineteen  years. 
Supposed  cause,  yellow  fever,  contracted  in  Brazil  in 
1 89 1.  The  first  convulsion  occurred  shortly  after  this. 
In  1893,  two  years  after  the  beginning  of  epilepsy,  he 
was  trephined  over  the  right  frontal  region.  Result, 
no  improvement ;  attacks  more  frequent  after  the  oper- 
ation than  before. 

Case  XIV. — A  young  man  aged  twenty  years. 
Family  history  negative.  Epilepsy  developed  at  the 
age  of  fifteen  years.  When  five  years  old  he  was 
pushed  off  a  wagon  and  injured  his  spine.  First 
attack  occurred  a  month  later.  A  year  after  that  he 
fell  from  an  engine  and  was  unconscious  some  time. 
In  September,  1900,  four  years  after  the  onset  of  his 
epilepsy,  he  was  trephined.     Result,  no  improvement. 

Case  XV. — A  boy  aged  fifteen  years.  Family  history 
negative.  Epilepsy  began  at  six  years.  Assigned 
cause,  trauma  from  being  struck  on  the  head  with  a 
shovel.  First  attack  occurred  a  month  later,  appear- 
ing three  or  four  days  after  that.  Nine  years  after  the 
injury  he  was  trephined  over  the  site  of  the  injury. 
Result,  epilepsy  worse  after  operation  than  before. 

Case  XVI. — A  young  man  aged  nineteen  years. 
Family  history  negative.  Supposed  cause,  trauma  to 
the  head  by  being  struck  by  a  train.  First  convulsion 
occurred  eight  years  later,  appearing  about  every  ten 
days  after  that.  Trephined  four  years  after  the  re- 
ceipt of  the  injury.  Result,  the  disease  was  worse 
after  the  operation. 


408         THE    SURGICAL    TREATMENT    OF    EPILEPSY. 

Case  XVII. — A  man  aged  twenty-nine  years.  Fam- 
ily history  negative.  Epilepsy  began  at  the  age  of 
twenty-one  years,  after  he  had  been  thrown  from  a 
wagon,  striking  on  the  back  of  his  head.  Trephined 
two  years  later.  Enjoyed  freedom  from  attacks 
four  months  after  that,  when  they  recurred.  After 
that  he  complained  of  severe  pains  in  his  head.  Re- 
sult, epilepsy  not  improved. 

Case  XVIII. — A  woman  aged  twenty  years.  Family 
history  negative.  Epilepsy  began  at  thirteen  years. 
First  convulsion  occurred  fifteen  months  after  the 
patient  fell,  striking  the  right  side  of  her  head  on  ice. 
Trephining  over  left  motor  area  in  November,  1894. 
During  the  five  months  following  the  operation  she 
had  no  seizures,  then  they  recurred  as  formerly,  and 
two  years  later  were  manifested  at  the  rate  of  four  or 
five  a  month.  Result,  some  temporary  but  no  perma- 
nent benefit. 

Case  XIX. — A  woman  aged  twenty-seven  years. 
Paternal  great-grandfather  and  grandfather  died  in- 
sane. Father,  alcoholic.  Two  maternal  aunts,  alco- 
holics. Maternal  uncle  died  insane.  Mother,  epileptic 
since  she  was  sixteen  years  old.  The  patient's  epilepsy 
began  at  the  eleventh  year.  Assigned  cause,  heredity. 
At  twenty  years  she  was  trephined  over  the  left  motor 
area  and  had  no  attacks  for  a  year  after  that.  Then 
the  attacks  recurred  as  bad  as  ever.  Result,  marked 
temporary  but  no  permanent  improvement. 

Case  XX. — A  man  aged  thirty-eight  years.  Family 
history  negative.  Epilepsy  began  at  twenty-seven 
years.  Assigned  cause,  injury  to  the  head  by  being 
caught  between  two  ice  wagons.  Trephined  over  the 
right  Rolandic  region  eight  years  after  the  injury. 
Result,  no  improvement. 

Case  XXI. — A  young  man  aged  twenty-two  years. 
Family  history  unknown,  except  that  all  (?)  the 
paternal  relatives  were  said  to  be  intemperate.  Epi- 
lepsy began  at  eleven  years.  Supposed  cause,  kicked 
by  a  horse.  Trephined  over  the  seat  of  the  injury; 
dura  found  thickened.     Result,  no  improvement. 

Case  XXII. — A  girl  aged  eight  years.  Father,  alco- 
holic. Epilepsy  began  at  two  years,  following  an 
infantile  cerebral  palsy.  Trephined  at  four  years. 
Skull  very  thick.     Result,  no  improvement. 


RESULTS    OF    SURGICAL    INTERVENTION.  409 

Case  XXIII. — A  woman  aged  thirty-eight  years. 
Family  history  unknown.  Epilepsy  began  at  eight 
years,  following  a  fall  downstairs.  A  second  injury 
was  caused  by  a  runaway  horse.  Convulsions  fol- 
lowed the  latter  accident  immediately.  She  was  un- 
conscious at  the  time,  remaining  so  for  three  days. 
Trephined  over  the  left  motor  area  at  the  end  of 
the  third  day.  The  convulsions  continued  with  vary- 
ing frequency  until  she  was  thirteen,  when  they 
entirely  disappeared  until  she  was  thirty.  Then  they 
returned  and  persisted  for  eight  years.  On  her  ad- 
mission to  the  Colony  her  uterus  was  found  impervious 
and  was  removed  with  both  ovaries.  Result,  three 
years  after  the  operation  she  had  suffered  no  further 
attacks ;  cure  probable. 

Case  XXIV. — A  girl  aged  nine  years.  Family  his- 
tory unknown.  Epilepsy  began  at  three  years.  No 
assigned  cause.  Three  years  later  she  was  trephined 
over  the  left  motor  area.     Result,  no  improvement. 

Case  XXV. — A  man  aged  thirty-two  years.  Multi- 
ple sclerosis.  Trephined  by  the  family  physician  in 
June,  1 90 1.  Operation  over  left  motor  area.  Result, 
no  improvement  in  epileptiform  symptoms  due  to  his 
multiple  sclerosis. 

Case  XXVI. — A  young  man  aged  twenty  years.  No 
occupation.  Epilepsy  of  six  years'  duration.  Right 
hemiplegia.  Jacksonian  type.  Trephined  by  Dr. 
Gerster  at  the  Mt.  Sinai  Hospital,  in  November,  1901. 
A  piece  of  bone  two  inches  and  a  half  square  was  re- 
moved.    Result,  no  improvement. 

Case  XXVII.— A  man  aged  forty  years.  Epilepsy 
came  on  a  year  previously.  Family  history  negative. 
Type  of  epilepsy,  both  grand  mal  and  petit  mat,  occur- 
ring frequently.  The  right  arm  and  left  leg  were  most 
frequently  affected.  Trephined  six  months  after  being 
injured  on  the  head  by  a  falling  stovepipe.  Attacks 
recurred  twelve  days  after  operation.  Result,  no 
improvement. 

Case  XXVIII. — A  boy  aged  ten  years.  Family  his- 
tory negative.  Epilepsy  of  nine  years'  duration. 
Cerebral  palsy;  right  hemiplegia.  Grand  mal  attacks 
beginning  on  the  right  side  of  the  face,  right  arm,  and 


4IO         THE    SURGICAL    TREATMENT    OF    EPILEPSY. 

leg.  Trephined  at  the  Colony  in  May,  1902.  Result, 
no  improvement  in  epilepsy. 

Case  XXIX. — A  man  aged  twenty-nine  years. 
Grand  mal  epilepsy  for  twenty-five  years.  Cause, 
typhoid  fever.  Paralysis  of  left  arm.  Trephined  at 
the  Massachusetts  General  Hospital  seven  years  before 
admission  to  the  Colony.     Result,  no  improvement. 

Case  XXX. — A  boy  aged  sixteen  years.  Epileptic 
since  the  second  year.  Cause  unknown.  Attacks  both 
mild  and  severe,  generally  beginning  in  the  left  hand, 
extending  up  the  arm  and  left  side  of  the  face  and 
head,  then  to  the  left  leg.  Trephined  at  the  Colony 
in  June,  1902.  No  marked  pathologic  condition 
found.     Result,  no  improvement. 

Case  XXXI. — A  boy  aged  sixteen  years.  Received 
a  fracture  of  the  skull  when  seven  years  old ;  trephined 
soon  afterward.  Epilepsy  came  on  two  years  after 
the  injury.  No  heredity ;  no  paralysis.  Attacks  aver- 
age two  or  three  a  month.     Result,  no  improvement. 

Case  XXXII. — A  man  aged  twenty-six  years. 
Epileptic  since  the  fourteenth  year.  Cause,  trauma  to 
the  head.  Type,  grand  mal.  Paralysis  of  the  right 
arm  and  leg,  and  left  side  of  the  face.  Trephined  in 
Syracuse  in  1899.  Result,  seizures  more  frequent  after 
the  operation. 

Case  XXXIII. — A  young  man  aged  twenty-one 
years.  Epileptic  since  the  seventeenth  year.  Cause, 
a  blow  on  the  head  by  a  pitchfork.  Grand  mal  con- 
vulsions. No  paralysis.  Trephined  over  the  right 
motor  area  previous  to  admission  to  the  Colony. 
Result,  no  improvement.     The  patient  is  an  imbecile. 

Case  XXXIV. — A  girl  aged  thirteen  years.  Epilep- 
tic since  the  sixth  year.  Epilepsy  followed  a  severe 
enterocolitis  attended  with  high  temperature  and  con- 
vulsions. A  condition  of  semispastic  rigidity  followed 
in  the  left  hand,  arm,  and  leg,  lasting  for  some  weeks. 
Her  attacks  occurred  at  the  rate  of  from  seven  to  ten 
a  day,  mostly  at  night.  They  usually  first  appeared 
in  the  left  hand,  and  extended  in  definite  order  each 
time.  All  of  the  attacks  were  essentially  motor;  there 
was  no  sensory  aura  of  any  kind,  and  as  soon  as  the 
fit  was  over  the  patient's  mental  condition  was  as 
clear  as  ever.     She   was  never  comatose   afterward, 


RESULTS    OF    SURGICAL    INTERVENTION.  4II 

though  she  occasionally  slept  from  exhaustion  follow- 
ing the  severer  attacks,  sleep  being  preceded  by  a 
few  moments  of  waking  state  following  the  fit.  Type 
of  attacks,  grand  mal  and  petit  mal.  Trephined  at  the 
Colony  in  May,  1903,  over  the  left  motor  area  by  Dr. 
Roswell  Park.  The  left  hand  center  was  located  by 
electrical  stimulation  and  completely  excised.  Noth- 
ing pathologic  was  found.  Result,  slight  improve- 
ment.* 

Twenty  out  of  the  thirty-four  cases  here  cited  were 
due  to  trauma  to  the  head,  or  to  supposed  trauma; 
the  rest  were  mostly  idiopathic,  some  having  a  distinct 
cause,  while  all  had  more  or  less  persistent  localizing 
symptoms.  In  six  of  them  the  operation  was  per- 
formed at  the  Colony;  the  rest,  by  skilled  surgeons 
elsewhere. 

The  average  duration  of  the  epilepsy  before  the 
operation  was  approximately  five  years  and  a  half, 
being  sixteen  years  in  one  case  and  three  days  in  an- 
other. In  no  case  (save  one)  was  the  result  noted  less 
than  eleven  months  after  the  operation ;  in  the  majority, 
several  years  had  intervened.  In  twenty-one  there 
was  no  improvement  in  the  disease,  the  attacks  being 
neither  lessened  in  frequency  nor  severity.  In  nine 
the  attacks  were  favorably  modified  to  some  extent. 
In  three  the  disease  was  much  worse,  this  being 
noticeably  true  in  Case  XIII,  in  which  the  cause  was 
yellow  fever,  and  the  operation  over  the  right  frontal 
region  was  performed  two  years  after  the  first  con- 
vulsion. 

In  one  case  only  was  there  apparent  recovery.  Here 
trephining  followed  trauma  to  the  head  at  eight  years, 
but  failed  to  check  the  epilepsy,  the  convulsions  con- 
tinuing five  years  longer,  when  they  spontaneously 
disappeared  to  recur  at  thirty.     So  the  apparent  cure 

*  It  is  entirely  too  early  to  speak  of  permanent  results  in  this  case.  Less 
than  three  months  had  elapsed  between  the  date  of  the  operation  and  the 
date  on  which  this  was  written. 


412         THE    SURGICAL    TREATMENT    OF    EPILEPSY. 

in  this  case  must  be  ascribed  to  the  results  of  ab- 
dominal section  and  not  to  the  earlier  operation  on 
the  brain. 

Twenty-eight  of  the  thirty-four  cases  were  males. 
Twelve  of  these  had  good  family  histories,  ten  were 
unfavorable  in  this  respect,  while  in  six  the  history 
■could  not  be  ascertained.  Of  the  six  women,  three 
had  good  family  histories,  two  had  not,  while  in  one 
it  was  unknown. 

It  is  worthy  of  note  that  none  of  the  patients  died 
as  the  result  of  the  operation. 

Similar  treatment  of  idiocy  and  imbecility  (craniec- 
tomy) is  attended  with  a  mortality  rate  of  from  20 
to  25  per  cent. 

As  a  rule,  epileptics  tolerate  surgical  operations 
well.* 

SEIZURE  RECORDS  IN   SIX   CASES   TREPHINED   AT  THE 
CRAIG   COLONY. 

Case  I. — Operated  April,  1900.  Case  II. — Operated  April,  1900. 

1900.  1901.  1900.  1901. 

January 559  1           January 3  4 

February .' 136  3           February 1  2 

March 131  3           March 7  1 

April 205  1           April 13  3 

May 14  2           May 1  3 

June o  o           June n  2 

July 3  2           July 1  3 

August o  4           August 1  1 

September o  7           September 6  6 

October o  7           October 1  8 

November o  1           November 5  3 

December 3  o           December 4  4 

Total 1051  31  Total 54  40 

*  From  the  "Ninth  Annual  Report  of  the  Craig  Colony,"  p.  44-  "Sixty- 
four  operations  of  importance  were  performed  in  the  Peterson  Hospital 
during  the  past  year;  three  were  capital  operations  on  the  brain;  five  were 
double  ovariotomies;  others  for  appendicitis,  resection  of  elbow,  etc.  From 
a  surgical  standpoint,  the  results  in  all  cases  were  uniformly  good,  all  opera- 
tions, without  exception,  being  followed  by  rapid  and  satisfactory  convales- 
cence." 


RESULTS    OF    SURGICAL    INTERVENTION.  413 

Case  III. — Operated  Nov.  25,  1900.  Case  IV. — Operated  May   7,    1902. 

1900.  1901.  1902.  1903. 

January 12  4  January o  5 

February 14  5  February o  n 

March 31  6  March o  3 

April 13  2  April 2  3 

May 19  3  May 4  0 

June 16  6  June 2  o 

July o  4  July 5  o 

August o  n  August 1  o 

September 5  14  September 2  o 

October 13  10  October 2  o 

November 2  12  November 4  o 

December o  9  December o  o 

Total 125  86  Total 22  22 

We  have  no  accurate  information  regarding  the 
seizures  in  Case  IV  before  admission,  and  are  unable 
to  compare  the  number  of  attacks  before  operation  with 
those  occurring  afterward. 

Case  V. — Operated  June  7,  1902. 

1902.  1903. 

January 10  25 

February 13  13 

March 208  75 

April 5  2 

May 6  o 

June 5  o 

July 13  ° 

August 7  o 

September 2  o 

October 7  o 

November 10  o 

December 18  o 

The  large  number  of  seizures  in  Case  V  in  March, 
1902,  was  due  to  status  epilepticus. 

Case  VI. — Operated  May  26,  1903. 

April  26 3  May  26     Operation. 

"     27 8       June     4 2 

"     28 12           "       5 o 

"     29 7           "       6 o 

"     30 2           "       7 1 

May     1 1           "      8 2 


414         TH-E    SURGICAL    TREATMENT    OF    EPILEPSY 

May    2 7      June  g 

3 9  "     i° 7 

4 4  "     ii 7 

5 i  "     is 6 


7 

June  9 

9 

" 

IO 

4 

" 

ii 

i 

" 

12 

4 

" 

13 

4 

" 

14 

3 

" 

15 

7 

" 

l6 

10 
5 
3 


10 1  17 7 

11 3  "  18 5 

12 1  "  19 6 

13 2  "  20 5 

14 2  "  21 3 

*5 3  "  22 3 


16 


3  23 


x7 3  "     24 o 

18 3  "     25 3 

19 4  "     26 6 

20 2  — 

Total  after 88 


23 
24 


"     26 1 

Total  before 111 

The  attacks  in  Case  VI  are  given  for  a  period  of 
twenty-eight  days  before  and  twenty-eight  days  after 
the  operation  only.  This  suffices  to  show  the  feature 
most  pronounced  after  surgical  intervention,  namely, 
the  temporary  benefit  the  patient  often  derives  that 
seldom  becomes  lasting. 

Briefly  noted,  the  results  in  the  foregoing  six  cases 
were  as  follows:  In  Case  I  there  were  1031  attacks 
during  the  four  months  preceding  the  operation. 
During  the  four  months  following  it  there  were  17 
only,  while  during  twenty  months  following  it  there 
were  51  attacks. 

In  Case  II  there  were  24  attacks  during  the  four 
months  preceding  the  operation,  and  fourteen  during 
the  four  months  following  it.  This  ratio  of  decrease 
kept  about  the  same  afterward. 


RESULTS    OF    SURGICAL    INTERVENTION.  415 

In  Case  III  there  were  125  attacks  during  the  eleven 
months  preceding  the  operation  and  66  during  the 
eleven  months  succeeding  it. 

In  Case  IV  the  number  before  the  operation  could 
not  be  ascertained.  During  the  first  twelve  months 
following  it  there  were  45. 

In  Case  V  there  were  242  attacks  during  the  five 
months  preceding  the  operation,  and  54  during  the 
five  months  succeeding  it;  while  during  the  ten 
months  following  it  there  were  193. 

In  Case  VI  there  were  1 1 1  attacks  during  the  twenty- 
eight  days  before  the  operation,  and  88  during  the 
same  period  after  it. 

It  will  thus  be  seen  that  while  absolute  cure  was 
not  obtained  in  any  of  the  thirty-four  cases  reported, 
a  marked  improvement  followed  in  about  a  fourth  of 
them.  Five  of  the  six  patients  trephined  at  the  Colony 
had  been  operated  on  previously. 

Matthiolus  collected  258  cases  of  Jacksonian  epi- 
lepsy, the  most  favorable  of  all  epilepsies  for  surgical 
treatment,  in  which  the  patients  were  subjected  to 
craniectomy.  "Some  20  per  cent,  were  reported  as 
cured,  though  only  ten  of  the  entire  number  had  been 
followed  for  over  three  years,  and  only  eighteen  of  them 
for  over  one  year.  Of  the  others,  15  per  cent,  were 
reported  improved;  56  per  cent,  unimproved;  13 
per  cent,  died."* 

Brown  collected  thirty  cases  due  to  trauma,  in 
which  thirteen  were  reported  cured,  nine  improved, 
and  eight  unimproved. 

Ferrier  reported  twenty-one  cases  of  partial  epilepsy, 
with  twelve  recoveries,  six  ameliorations  and  negative 
results  in  three;  adding,  "it  must  be  remembered 
that  such  observations  are  often  published  before  six 
months  have  elapsed." 

*  Roswell  Park,  "American  Medicine,"  Vol.  IV,  Nov.  21,  1902. 


41 6         THE    SURGICAL    TREATMENT    OF    EPILEPSY. 

Starr*  gives  the  surgical  results  in  twenty-nine  cases 
as  follows:  "Cured  ten,  improved  six,  not  improved 
eleven,  died  two." 

It  must  be  noted,  however,  that  these  conclusions 
were  drawn  some  years  ago  (1892)  when  results  were 
reported  sooner  after  the  operation  than  is  generally 
done  at  the  present  time.  Most  of  them  were  noted 
at  three,  four,  six,  and  eight  months  after  operation. 

It  is  apparent  to  the  unbiased  student  of  epilepsy 
long  familiar  with  the  disease  in  its  many  aspects, 
that  conservative  surgery  has  a  place  of  value  in  its 
treatment. 

It  is,  at  the  same  time,  fully  as  apparent  that  much 
of  the  surgical  treatment  of  epilepsy  of  the  past  was 
done  under  less  knowledge  of  the  etiology  and  path- 
ology of  epilepsy  than  need  be  the  case  to-day.  Our 
advancing  conception  of  its  pathogenesis  seems  likely 
now  to  restrict  surgical  work  in  its  treatment  still 
further  than  is  the  case  to-day. 

Neither  the  epileptologist  nor  the  surgeon  can  at 
this  time  better  advise  as  to  the  probable  cause  of 
capital  surgical  intervention  for  the  possible  relief  of 
idiopathic  epilepsy  than  to  say :  It  is  one  of  the  most 
obstinate  diseases  of  the  brain  the  physician  is  called 
upon  to  treat.  After  all  other  treatment,  fairly  tried, 
has  failed,  a  surgical  operation  may  offer  relief;  far 
less  often  it  promises  cure. 

The  majority  of  those  operated  on  experience  no 
benefit,  while  about  a  fourth  are  aided  some.  Under 
ordinary  circumstances  and  strict  antiseptic  precau- 
tions, little  danger  is  to  be  feared  from  the  operation 
itself. 

TECHNIQUE  OF  TREPHINING  IN  EPILEPSY. 

Preparation  of  the  Patient. — The  patient's  head 
should  be  entirely  shaved  the  day  before  the  operation ; 

*  "Brain  Surgery,"  1893,  pages  55  to  67. 


TECHNIQUE    OF    TREPHINING    IN    EPILEPSY.         417 

the  scalp  washed  with  soap  and  water  and  thoroughly 
scrubbed  with  a  nail  brush,  after  which  it  should  be 
washed  with  ether,  and  finally  with  a  i  :  iooo  solution 
of  bichlorid  of  mercury.  An  aseptic  gauze  dressing 
wet  with  a  i  :  2000  solution  of  mercuric  bichlorid  is 
then  put  on  and  held  in  place  by  a  properly  applied 
bandage  which  is  left  in  position  until  the  operation. 

Immediately  preceding  the  operation  a  quarter  of  a 
grain  of  morphin  sulphate  or  two  drachms  of  the  fluid 
extract  of  ergot  may  be  given  for  the  purpose  of  con- 
tracting the  cerebral  blood-vessels  and  diminishing 
hemorrhage.  Suspension  of  the  bromids  for  Some 
days  before  the  operation  has  been  advocated,  but 
it  is  best  to  continue  them  sparingly  for  fear  of  status. 

Immediately  before  beginning  the  anesthetic,  the 
dressing  on  the  head  may  be  removed  and  the  point 
of  attack  carefully  mapped  out.  To  do  this  success- 
fully, a  knowledge  of  cerebral  localization  and  of 
the  surgical  anatomy  of  the  skull  and  brain  is  essential. 
The  center  to  be  attacked  must  be  determined  by  the 
localizing  symptoms  exhibited  during  the  convulsions, 
and  the  point  on  the  skull  under  which  such  center 
lies  marked  for  identification. 

In  epilepsy  following  traumatism  to  the  skull, 
where  evidences  of  injury  are  superficially  apparent, 
it  may  not  be  necessary  to  resort  to  accurate  measure- 
ments to  locate  the  point  at  which  to  trephine.  When 
the  evidences  of  trauma  and  the  localizing  symptoms 
do  not  point  to  the  same  portion  of  the  brain,  the 
skull  should  be  opened  at  the  point  indicated  by  the 
localizing  symptoms.  The  medical  rather  than  the 
surgical  indications  in  such  cases  are  more  likely  to 
guide  us  to  the  seat  of  irritation. 

In  cases  of  traumatic   epilepsy  without  localizing 

symptoms,    when    the    trauma    involves    a    so-called 

silent  portion  of  the  cortex,  the  external  signs  of  injury 

may  be  the  only  guide.     In  the  majority  of  cases  the 

21 


41 8         THE    SURGICAL    TREATMENT    OF    EPILEPSY. 


centers  most  frequently  sought  lie  about  the  fissure 
of  Rolando,  so  that  the  accurate  location  of  the  fissure 
is  of  great  importance.  The  location  of  the  fissure  of 
Sylvius  is  not  so  important,  but  in  some  cases  with 
aphasic  or  auditory  symptoms  it  must  be  mapped  out. 
The  fissure  of  Rolando  is  located  by  drawing  a  line 
on  the  scalp  from  the  root  of  the  nose  to  the  external 
occipital  protuberance.  A  point  thirteen  millimeters 
posterior  to  the  middle  of  this  line  lies  above  the  upper 
end  of  the  fissure  which  runs  downward  and  forward 
from  this  point  at  an  angle  of  670.     This  fissure  is 

about  3-f  inches  long  and  its 
lower  third  is  slightly  more 
vertical  in  direction  than  its 
upper  two-thirds. 

Many  methods  have  been 
suggested  for  marking  the 
location  of  this  fissure  on  the 
scalp.  One  of  the  simplest, 
and  which  for  practical  pur- 
poses is  sufficient,  is  that  of 
Chiene,  who  folded  a  square 
of  paper  diagonally.  (See 
diagram.)  The  angle  BAG 
is  450.  By  again  folding  the  paper  and  bisecting  the 
angle  C  A  D,  the  angle  E  A  D  is  formed,  which  is  22^°. 
The  angle  E  A  B  is  67^°.  This  angle  is  accurate 
enough  for  practical  purposes,  and  if  the  side  of  the 
paper  A  B  is  now  placed  on  the  scalp  coinciding  with 
the  line  joining  the  root  of  the  nose  and  the  external 
occipital  protuberance,  the  point  A  being  placed  thir- 
teen millimeters  posterior  to  the  middle  of  this  line 
and  the  side  A  B' running  forward  from  that  point,  the 
side  of  the  paper  A  E  will  indicate  the  position  of  the 
fissure,  which  can  be  marked  on  the  scalp  with  iodin 
or  an  anilin  pencil.  A  few  touches  of  the  cautery  will 
serve  to  make  the  line  indelible  and  recognizable  after 
the  final  washing  of  the  scalp. 


Fig.  16. — Chiene's  method 
of  fixing  position  of  Rolandic 
fissure. 


Plat 


Fissure    of  S 


Cortical  centers  of  the  brain,  out' 


^Fissure  oF  Rolando 


*  S  nr>  u  1  ^\x^S" 

AboL  /Cr 

risf  £/ 


Pariet-o-  occip 
Fissure. 


surface  (modified  from  Dalton). 


TECHNIQUE    OF    TREPHINING    IN    EPILEPSY.         419 

The  fissure  of  Sylvius  is  located  by  drawing  a  line 
directly  backward  from  the  external  angular  process 
for  an  inch  and  a  quarter  and  then  upward  for  a  quarter 
of  an  inch.  A  line  is  then  drawn  from  this  last  point 
to  a  point  three-quarters  of  an  inch  below  the  most 
prominent  portion  of  the  parietal  eminence.  This 
line  lies  over  the  horizontal  portion  of  the  fissure. 
The  point  of  junction  between  the  horizontal  and 
ascending  branches  of  this  fissure  lies  about  two  inches 
behind  and  slightly  above  the  external  angular  process 
of  the  frontal  bone,  the  ascending  branch  running 
upward  from  this  point  for  three-quarters  of  an  inch 
behind  the  coronal  suture. 

The  location  of  the  desired  fissure  having  been 
marked  on  the  scalp,  the  exact  point  at  which  the 
center  pin  of  the  trephine  is  to  be  placed  must  also  be 
determined  and  marked.  The  anesthetic  is  next  given, 
the  scalp  again  washed  with  a  i :  iooo  solution  of  bi- 
chlorid,  and  the  head  placed  in  a  good  light  on  a  firm 
support.  After  the  patient  is  anesthetized,  the  skull 
should  be  marked  at  the  point  to  be  trephined  by 
puncturing  the  scalp  at  the  point  with  the  center  pin 
of  a  trephine  or  other  instrument  and  nicking  the 
bone.  The  scalp  may  also  be  punctured  at  two  points 
along  the  line  indicating  the  direction  of  the  fissure, 
the  bone  being  marked  deeply  enough  to  be  recognizable 
after  the  scalp  flap  is  reflected.  Unless  the  bone  be 
marked  in  this  manner,  it  is  difficult  to  decide  at  what 
point  the  trephine  should  be  applied. 

While  these  directions  are  useful  in  determining  the 
point  of  attack,  the  skilled  surgeon,  especially  in 
Jacksonian  cases,  often  dispenses  with  them,  making 
the  incision  simply  over  the  motor  area,  and  removing 
sufficient  bone  to  permit  extensive  exploration  of  the 
cortex  by  means  of  electric  stimulation.  The  seat 
of  disease  can  often  be  better  detected  in  this  way  than 
by  the  most  careful  external  measurements.  The 
cortex  need  not  be  exposed  to  apply  the  faradic  cur- 


420         THE    SURGICAL    TREATMENT    OF    EPILEPSY. 

rent.  Stimulation  can  as  well  be  obtained  by  applying 
the  electrodes  to  the  dura  before  it  is  opened.* 

Instruments. — The  following  instruments  should 
be  in  readiness:  two  scalpels,  a  periosteal  elevator,  a 
trephine,  a  rongeur,  a  pair  of  small  blunt  scissors,  a 
tenaculum,  a  pair  of  dressing  forceps,  a  probe,  a  grooved 
director,  some  fine  curved  needles,  a  small  spatula,  a 
number  of  artery  forceps,  catgut  and  silk  ligatures. 
A  Paquelin  cautery,  a  faradic  battery,  and  a  small 
electrode  (like  Keen's)  may  be  required;  and  Horsley's 
wax— composed  of  wax  seven  parts,  carbolic  acid  one 
part,  and  oil  two  parts — may  be  useful  during  the 
operation. 

Operation. — The  incision  should  be  made  base  down- 
ward, semi-circular  or  horseshoe  in  shape,  with  due 
regard  for  the  blood-supply  of  the  flap  and  subsequent 
drainage  of  the  wound,  should  this  be  necessary. 
The  incision  should  be  ample  in  extent  to  give  room 
for  removing  the  necessary  bone  without  further 
enlargement  of  the  scalp  opening,  or  having  the  edge 
of  the  bone  opening  encroach  too  near  to  the  line  of 
incision  in  the  scalp.  The  scalp  incision  can  be 
made  with  one  or  two  sweeps  of  the  knife,  prompt 
pressure  with  gauze  sponges  being  used  to  control  the 
hemorrhage  as  the  incision  is  made.  Bleeding  points 
at  the  flap  edges  are  caught  up  with  artery  forceps 
and  the  hemorrhage  promptly  controlled.  These 
forceps  can  be  left  in  place  for  some  time. 

The  flap  is  raised,  the  periosteum  reflected,  and  the 
bone  laid  bare.  The  center  pin  of  the  trephine  is  then 
placed  at  the  spot  previously  marked  on  the  bone  and 
the  instrument  applied  vertically  to  the  plane  of  the 
portion  of  the  skull  attacked.  After  the  bone  is 
grooved  sufficiently,  the  center  pin  is  withdrawn  and 

*The  choice  of  an  anesthetic  is  important;  if  chloroform  be  used  the 
head  should  be  slightly  raised  to  lessen  the  danger  of  hemorrhage.  [See 
"Anesthesia,"  under  Abdominal  Section.] 


Plate  23. 


Instruments  Used  in  Trephining  for  Epilepsy. 
1,  Scalpel;  2,  3,  large  and  small  trephines;  4,  5,  bone-cutting  forceps; 
6,   dressing  forceps;    7,   grooved  director;   8,   forcipressure ;  9,   probe;    10, 
Horsley's  dural  separator;  n,  Keen's  electrode;  12,  scissors. 


TECHNIQUE    OF    TREPHINING    IN    EPILEPSY.         42 1 

the  trephining  continued  carefully,  the  operator 
remembering  that  the  skull  may  differ  considerably 
in  thickness  at  different  points  in  the  circumference 
of  the  trephine  opening.  The  trephine  must  be  with- 
drawn at  times  to  free  it  from  bone  detritus  and  to 
permit  the  exploration  of  the  opening  by  means  of  a 
probe  to  see  if  the  cranium  has  been  cut  through  at 
any  point. 

When  the  diploe  has  been  entered,  the  resistance 
to  the  trephine  will  be  lessened  and  blood  will  appear 
in  the  opening.  When  the  inner  table  has  been  cut 
through,  the  button  of  bone  will  be  movable,  and  it 
may  be  removed  either  by  rocking  the  trephine  or  by 
prying  it  up  with  an  elevator.  The  trephine  used 
should  by  preference  be  large,  or  two  or  more  openings 
may  be  made  with  a  smaller  instrument  and  the  inter- 
mediate bone  cut  away  with  rongeur  forceps.  What- 
ever the  method,  there  should  be  no  hesitancy  in 
removing  sufficient  bone  to  give  ample  room  for  ex- 
ploration and  the  space  necessary  for  doing  any 
operation  the  conditions  may  demand.  It  is  always 
a  mistake  to  attempt  to  operate  through  a  small 
opening. 

After  the  button  of  bone  is  removed,  it  is  well  to 
separate  any  adhesions  between  the  bone  and  dura 
about  the  opening  by  means  of  Horsley's  dural  sepa- 
rator, or  a  probe  bent  at  an  angle,  before  enlarging 
the  opening  with  the  rongeur.  In  cutting  away  the 
bone,  if  the  field  of  operation  is  in  the  vicinity  of  any 
of  the  sinuses,  care  must  be  taken  not  to  injure  these 
structures.  Fortunately,  operations  for  the  relief 
of  epilepsy  are  not  frequently  done  near  a  sinus  and 
the  danger  from  this  source  is  not  great.  The  hemor- 
rhage from  the  bone  is  often  considerable,  but  can 
usually  be  controlled  by  pressure  with  hot  compresses, 
by  plugging  the  bleeding  point  with  a  few  strands  of 
catgut,   gauze,   or  even  with  a  piece  of  match  or  a 


42  2         THE    SURGICAL    TREATMENT    OF    EPILEPSY. 

toothpick;  also  by  the  use  of  Horsley's  wax  or  the 
actual  cautery.  If  these  do  not  suffice,  the  two 
tables  of  the  skull  may  be  forcibly  crushed  together 
at  the  bleeding  point  with  heavy  forceps.  Should  a 
sinus  be  wounded,  the  hemorrhage  may  be  controlled 
by  plugging  with  gauze. 

When  the  dura  has  been  sufficiently  exposed,  it 
should  be  opened  by  lifting  it  away  from  the  under- 
lying structures  with  a  tenaculum  and  incising  it 
with  the  point  of  a  scalpel.  The  incision  can  then  be 
carried  around  parallel  with  the  edge  of  the  bone 
opening  and  about  a  quarter  of  an  inch  away  from  it, 
making  a  flap  in  the  dura  with  its  base  downward. 
If  any  of  the  large  branches  of  the  middle  meningeal 
artery  are  encountered,  a  ligature  of  catgut  can  be 
passed  under  them  by  using  a  fine  curved  needle 
and  the  vessel  ligated  before  the  dura  is  opened. 

After  the  dura  is  opened,  the  further  course  of  the 
operation  will  depend  on  the  conditions  found. 
Adhesions  between  the  dura  and  the  underlying 
membranes  about  the  margin  of  the  opening  should  be 
broken  up  with  a  probe  properly  bent.  This  may  be 
done  before  the  dural  flap  is  made  by  introducing  the 
probe  through  the  first  incision  made  in  the  dura  and 
sweeping  it  around  carefully.  On  opening  the  dura 
the  appearance  of  the  brain  may  give  valuable  aid  in 
diagnosis.  At  times,  the  pia  may  be  so  edematous 
as  to  obscure  the  outlines  of  the  convolutions.  In  such 
cases  it  will  be  necessary  to  incise  the  pia  to  allow 
the  escape  of  the  fluid  and  permit  an  inspection  of 
the  surface  of  the  brain. 

Bulging  of  the. brain  into  the  trephine  opening  is 
an  evidence  of  increased  intracranial  tension  which 
may  be  due  to  the  presence  of  a  cyst,  tumor,  abscess, 
or  internal  hydrocephalus.  Absence  of  pulsation  in 
the  part  of  the  brain  presenting  is  also  evidence  of  the 
same  conditions.     Discoloration  of  the   surface   may 


TECHNIQUE    OF    TREPHINING    IN    EPILEPSY.         423 

be  an  indication  of  tumor  beneath  the  cortex.  Pal- 
pation also  gives  valuable  information.  Undue  firm- 
ness is  indicative  of  tumor;  fluctuation,  of  an  abscess 
or  cyst.  The  brain  can  be  depressed  carefully  and 
the  ringer  introduced  under  the  dura  and  swept 
around  the  margins  of  the  opening  and  the  cortex 
explored  for  some  distance. 

Sufficient  information  can  usually  be  obtained  by 
inspection  and  palpation,  but  if  necessary  the  brain 
may  be  explored  with  the  hypodermic  needle  or  by 
incision.  The  latter  methods  should  not  be  resorted 
to  indiscriminately  and  will  not  often  be  necessary  in 
operations  for  the  relief  of  epilepsy.  If  the  brain  be 
explored  by  puncture  or  incision,  the  entrance  should 
be  made  over  the  summit  of  a  convolution  and  the 
direction  of  the  incision  should  be  vertical  to  the  por- 
tion of  brain  attacked.  Scars  in  the  dura  or  cortex 
resulting  from  old  lacerations'  should  be  sought  for. 
Depressed  bone  and  bone  splinters  demand  removal, 
and  adhesions  should  be  broken  up  wherever  found. 
The  remains  of  old  clots  can  be  removed  by  gentle 
wiping  with  gauze  with  the  assistance  of  irrigation 
with  warm  sterile  water. 

Cysts  are  best  treated  by  excision  whenever  prac- 
ticable ;  where  they  cannot  be  dissected  out,  the  super- 
ficial portion  may  be  removed,  the  interior  emptied, 
cauterized,  and  drained.  Tumors,  when  encapsu- 
lated, can  be  enucleated  with  scissors  and  spatula. 
When  not  encapsulated,  they  must  be  removed  by 
dissection  through  the  healthy  tissue.  Scars  in  the 
dura  should  be  excised,  while  cortical  scars  should  be 
carefully  dissected  out  with  scalpel  and  scissors. 

Scars  of  the  cortex  to  be  removed  can  be  outlined 
with  the  scalpel  and  cut  away  with  scissors.  In  doing 
this  there  is  less  danger  of  wounding  other  important 
cortical  centers  by  incisions  made  in  the  anteropos- 
terior direction  than  by  incisions  made  from  above 


424         THE    SURGICAL    TREATMENT    OF    EPILEPSY. 

downward.  Such  incisions  need  seldom  extend  deeper 
than  the  gray  matter,  unless  the  condition  demanding 
removal  extends  more  deeply.  In  certain  cases  none 
of  these  pathologic  conditions  may  be  apparent,  and 
excision  of  the  cortical  center  controlling  that  part  of 
the  body  in  which  the  convulsive  movements  have 
their  origin  may  be  considered. 

The  center  is  located  by  faradization  of  the  cortex 
with  a  pair  of  small  electrodes,  using  a  mild  current. 
The  electrodes  must  be  sterilized  before  using  them 
and  the  handles  wrapped  in  sterile  gauze  when  in  use. 
Antiseptic  solutions  must  not  come  in  contact  with 
the  electrodes  when  in  use,  as  they  interfere  with 
electric  action.  When  the  center  is  located,  it  is  re- 
moved in  the  manner  described  above  for  excising 
scars  of  the  cortex.  If  benefit  is  to  follow  such  pro- 
cedure, the  removal  must  be  thorough  and  the  entire 
center  excised. 

In  the  course  of  such  operation,  hemorrhage  either 
from  the  pia  or  the  brain  substance  may  be  troublesome. 
If  from  the  pia,  it  may  be  controlled  by  pressure  with 
hot  compresses  or  by  the  cautery.  It  may  be  possible 
at  times  to  tie  off  with  fine  catgut  the  bleeding  portion 
of  the  pia  en  masse.  If  from  the  brain  substance,  it 
may  be  controlled  by  pressure  with  gauze  wrung  out 
of  hot  sterile  water.  A  1 :  40  solution  of  antipyrin 
recommended  by  Park,  or  a  1 :  100  solution  of  cocain 
recommended  by  Keen,  is  a  useful  styptic.  A  1 :  1000 
solution  of  adrenalin  chlorid  may  be  applied,  and  is 
usually  effective  in  lessening  this  form  of  hemorrhage. 
If  the  bleeding  is  excessive  and  persistent,  the  wound 
may  be  tamponed  with  gauze. 

After  the  source  of  irritation  has  been  removed  as 
thoroughly  as  possible,  the  wound  is  closed.  In  every 
case  the  dura  should  be  closed,  if  possible ;  a  continu- 
ous suture  of  fine  catgut,  applied  by  means  of  a  small 
curved  needle,  being  used  for  this  purpose.     In  cases 


TECHNIQUE    OF    TREPHINING    IN    EPILEPSY.         425 

where  cysts  or  tumors  have  been  removed  and  the 
resulting  cavities  are  packed  with  gauze,  or  where 
drainage  of  any  kind  is  used,  it  will,  of  course,  be 
impossible  to  close  the  dura  completely.  In  such 
cases  an  opening  may  be  left  at  the  most  dependent 
portion  of  the  dural  flap,  through  which  the  drainage 
material  may  pass. 

On  account  of  the  danger  of  adhesions  forming  after 
such  operations,  the  introduction  of  some  material 
to  prevent  their  formation  is  necessary.  While  no 
perfectly  satisfactory  method  has  been  devised  for 
attaining  this  end,  the  insertion  of  gold  foil  is,  perhaps, 
as  satisfactory  as  any.  If  it  is  used,  a  piece  large 
enough  to  completely  cover  the  exposed  cortex  and 
extend  under  the  margins  of  the  dural  opening  should 
be  carefully  inserted  before  the  dura  is  sutured. 
Suture  of  the  dura  may  be  interfered  with  by  protru- 
sion of  the  brain  through  the  opening.  This  may  be 
overcome  by  pressing  it  back  with  small  spatulas  in- 
serted under  the  dura  while  the  suturing  is  in  progress. 

It  is,  perhaps,  better  not  to  attempt  replacing  the 
bone  in  these  cases.  The  scalp  is  closed  with  silk 
sutures.  Gauze  drainage  may  be  used,  if  necessary, 
or  a  few  strands  of  silkworm  gut  may  suffice.  In  cases 
where  it  is  important  to  insure  patency  of  the  scalp 
wound  and  efficient  drainage,  the  gauze  drainage 
material  may  be  allowed  to  separate  the  edges  of  the 
scalp  wound  for  some  distance  at  the  dependent 
portion  of  the  opening.  Silk  sutures  are  introduced 
at  regular  intervals  along  the  scalp  edges  at  this  part 
of  the  wound,  but  left  untied  until  the  drainage  is 
removed  on  the  second  or  third  day.  An  abundant 
aseptic  dressing  is  finally  applied.  Where  no  drainage 
is  used,  and  there  are  not  symptoms  to  the  contrary, 
this  dressing  may  be  left  in  place  for  a  week  or  ten  days, 
when  the  wound  will  probably  be  completely  healed. 
When  drainage  of  a  cyst  or  brain  cavity  has  been 


426         THE    SURGICAL    TREATMENT    OF    EPILEPSY. 

effected,  it  will  be  necessary  to  dress  the  wound  more 
frequently  and  to  gradually  remove  the  drainage  in 
accordance  with  the  demands  of  the  case.  In  any 
case,  excessive  discharge  resulting  in  extensive  staining 
of  the  dressing  calls  for  its  removal  and  reapplication. 
Symptoms  of  pressure  from  retained  secretions  de- 
mand the  removal  of  the  dressing  and  the  examination 
of  the  wound.  In  such  cases  it  may  be  necessary  to 
remove  one  or  two  sutures  to  permit  the  escape  of 
these  secretions.  An  increase  in  temperature  with 
evidences  of  infection  calls  for  the  immediate  examina- 
tion of  the  wound.  As  a  rule,  the  sutures  may  be 
removed  eight  or  ten  days  after  the  operation.* 

ABDOMINAL    SECTION. 

Indications  for  Abdominal  Section  for  the  Possible 
Relief  of  Epilepsy. — In  this  connection  the  acute  in- 
flammatory and  malignant  diseases  that  affect  the 
reproductive  organs  in  women  and  which  may  require 
operation  irrespective  of  the  presence  of  epilepsy,  are 
not  considered. 

The  pathologic  conditions  within  the  abdomen,  which 
may  be  a  factor  in  causing  or  increasing  the  frequency 
of  epileptic  seizures,  are  generally  those  affecting  the 
ovaries  and  uterus,  the  condition  having  persisted  a 
sufficient  length  of  time  to  set  up  reflex  nervous 
symptoms. 

In  some  cases  of  severe  dysmenorrhea  the  ovaries 
will  be  found  enlarged  and  with  numerous  cysts 
beneath  a  thickened  capsule.  This  may  be  a  real 
excitant  to  determine  the  epileptic  seizures  at  the 
menstrual  period,  and  it  constitutes  one  of  the  so- 
called    menstrual    epilepsies.     The    removal    of    such 

*  References. — "Hospital  Records  at  Craig  Colony."  Esmarch  and 
Kowaltzig,  "Surgical  Technique."  Bryant,  " Operative  Surgery."  Dennis, 
"System  of  Surgery."  "American  Text-book  of  Surgery."  Deaver, 
"Surgical  Anatomy."  Senn,  "Practical  Surgery."  Tillmanns  "Text- 
book of  Surgery."     Starr,  "Brain  Surgery." 


ABDOMINAL    SECTION.  427 

ovaries  often  lessens  the  frequency  and  severity  of  the 
epileptic  seizures. 

When  the  ovaries  are  normal  and  the  epileptic 
seizures  are  more  frequent  at  the  menstrual  period, 
they  should  not  be  removed.  A  dysmenorrhea  may 
be  relieved,  but  the  mental  and  nervous  symptoms 
which  follow  the  artificial  production  of  the  meno- 
pause will  be  likely  to  increase  the  tendency  to  mental 
failure  so  frequently  a  result  of  epilepsy  as  it  is. 

Anterior  and  posterior  displacements  of  the  uterus, 
with  the  ovaries  and  tubes  bound  down  by  firm  adhe- 
sions, also  constitute  conditions  productive  of  reflex 
symptoms  in  various  parts  of  the  body,  and  may  act 
unfavorably  upon  the  patient's  epilepsy. 

In  rare  cases  the  uterus  may  be  a  retention  cyst, 
the  pain  and  reflex  symptoms  due  to  the  retained 
menstrual  flow  becoming  so  intense  in  predisposed 
subjects  at  the  menstrual  period  as  to  produce  distinct 
epileptic  phenomena — convulsions  that  closely  simu- 
late the  true  disease,  and  which,  in  selected  cases, 
may  eventually  pass  into  it,  so  far  at  least  as  the  final 
effects  are  concerned.  Mention  has  previously  been 
made  of  a  woman  at  the  Colony  who  had  this  condi- 
tion, the  relief  of  which  through  removal  of  the  uterus 
and  ovaries  checked  all  further  attacks. 

It  behooves  us  to  make  careful  inquiry  into  the 
possible  influence  of  perverted  functions  on  the  part 
of  the  reproductive  organs  in  any  case  of  epilepsy 
among  women  occurring  after  puberty  and  before  the 
menopause. 

In  some  cases  in  which  epilepsy  comes  on  before 
puberty,  or  arises  after  it,  independent  of  any  disease 
of  the  ovaries  or  uterus,  operation  may  be  justified 
on  the  score  of  lessening  the  frequency  and  severity 
of  epileptic  attacks  that  are  often  prone  to  great 
augmentation  at  the  monthly  flow.  But  it  is  not  an 
operation  under  any  circumstances  for  indiscriminate 


428         THE    SURGICAL    TREATMENT    OF    EPILEPSY. 

adoption.  It  requires  careful  selection,  and  then  it 
must  be  regarded  in  most  cases  as  a  part  of  the  treat- 
ment only. 

TECHNIQUE  OF  ABDOMINAL  SECTION. 

Preparation  of  the  Patient  for  Abdominal  Section. — 

As  most  of  the  cases  requiring  operation  are  of  a 
chronic  nature,  the  time  selected  for  the  operation 
should  be  a  period  most  remote  from  the  attacks. 
Usually  this  is  not  difficult  when  the  attacks  are  prone 
to  occur  in  series  about  the  menstrual  epoch. 

The  patient  should  be  thoroughly  prepared  for  the 
operation  by  observing  the  following  points  for  a  week 
beforehand :  The  urine  should  be  carefully  examined  a 
number  of  times.  If  the  patient  is  not  taking  bromid, 
it  is  generally  best  to  give  some  form  of  the  drug  in 
moderate  amount  during  the  operating  period.  The 
diet  should  be  restricted  to  easily  digested  foods, 
giving  nothing  but  liquids  for  a  day  before  the  opera- 
tion, and  no  food  at  all  for  six  hours  before  the  anes- 
thetic. A  saline  cathartic  should  be  given  twenty-four 
hours  before;  an  enema  the  night  before  and  on  the 
morning  of  the  operating  day. 

Following  the  warm  bath  on  the  day  preceding  the 
operation,  the  skin  of  the  abdomen  is  prepared  by 
scrubbing  with  potash  soap  and  warm  water ;  all  hair 
is  shaved  from  the  abdomen  and  pubes ;  a  poultice  of 
green  soap  is  applied  over  the  abdomen  and  retained 
for  three  or  four  hours;  the  abdomen  is  scrubbed 
again  with  soap  and  sterile  gauze  sponges  and  all  soap 
is  removed  with  sterilized  water ;  it  is  then  scrubbed 
with  alcohol  and  ether  and  washed  with  a  1  :  1000  solu- 
tion of  bichlorid  of  mercury;  a  pad  of  gauze  and  ab- 
sorbent cotton  saturated  with  a  1  :  4000  bichlorid  solu- 
tion is  then  applied  and  kept  on  until  the  time  of  the 
operation. 

A  vaginal  douche  with  hot  soapsuds,  followed  by  a 


ABDOMINAL    SECTION.  429 

i  :  5000  bichlorid  solution  is  given  on  the  morning  of 
the  operation.  If  any  discharge  is  present,  this  treat- 
ment is  given  for  several  days  previous  to  the  operation. 
The  cleaning  of  the  vagina  may  be  postponed  until 
the  patient  is  under  the  anesthetic,  when  it  is  scrubbed 
with  green  soap  on  cotton  sponges,  but  it  should  be 
done  in  all  cases,  especially  when  the  uterus  is  to  be 
operated  upon. 

Preparation  of  the  Operator  and  Assistants. — A  part 
of  the  outside  clothing  should  be  removed  and  a  sterile 
gown  or  duck  suit  worn  by  the  operator  and  assistants. 
A  rubber  apron  may  be  worn  under  the  gown  to  pro- 
tect the  clothing,  and  a  sterile  linen  cap  should  cover 
the  hair  of  the  head. 

The  hands  and  forearms  should  be  thoroughly 
scrubbed  with  potash  soap  and  hot  water,  using  a 
sterile  brush.  Then  immerse  the  hands  for  two  min- 
utes in  95  per  cent,  alcohol  and  thoroughly  clean  the 
nails  and  fingers.  Finally  the  hands  and  forearms  are 
immersed  in  a  i  :  iooo  solution  of  mercury  bichlorid  for 
a  few  minutes,  and  then  rinsed  in  sterile  water. 

Everything  that  comes  in  contact  with  the  field  of 
operation  must  be  sterile. 

Instruments  are  best  sterilized  by  boiling  for  thirty 
minutes  in  a  one-per-cent.  solution  of  carbonate  of 
soda.  If  they  are  put  in  the  water  after  it  has  begun 
to  boil,  the  danger  of  rusting  will  be  lessened. 

Silk  for  sutures  and  ligatures  may  be  sterilized  by 
steam  or  by  boiling  in  a  one-per-cent.  soda  solution. 

Silkworm  gut  is  sterilized  by  superheated  steam  or 
by  boiling  in  plain  water. 

Silver  wire  may  be  boiled  in  a  solution  of  carbonate 
of  soda,  or  it  may  be  heated  direct  in  the  flame  of  an 
alcohol  lamp. 

Catgut  is  rendered  sterile  by  boiling  after  first  treat- 
ing it  with  formalin,  according  to  the  method  of  Hof- 
meister.     The  catgut  is  wound  on  glass  rods  or  plates 


43©        THE    SURGICAL    TREATMENT    OF    EPILEPSY. 

and  immersed  in  a  two-  to  four-per-cent.  solution  of 
formalin  for  from  twelve  to  forty-eight  hours  and  then 
washed  in  running  water  to  remove  the  formalin.  It 
is  next  boiled  for  thirty  minutes  and  then  preserved 
in  alcohol  containing  five  per  cent,  of  glycerin  and 
one-tenth  of  one  per  cent,  of  mercury  bichlorid. 

Dressings,  towels,  etc.,  are  sterilized  by  steam  under 
pressure. 

Plenty  of  sterilized  normal  salt  solution,  hot  and 
cold,  should  be  ready. 

Anesthesia. — Ether  is  the  safer  anesthesia  in  most 
cases.  By  starting  with  chloroform  and  changing 
when  narcosis  is  well  under  way  to  ether,  some  of  the 
unpleasant  effects  of  the  latter  can  be  avoided.  Before 
giving  the  anesthetic,  the  bladder  should  be  emptied, 
using  a  catheter  if  necessary.  A  hypodermic  injection 
of  morphin  sulphate,  £  to  I  of  a  grain,  and  atropin, 
t^tj-  to  TV  of  a  grain,  given  just  before  the  operation, 
will  lessen  nervous  excitability  and  render  the  adminis- 
tration of  the  anesthetic  safer  and  easier. 

When  the  patient  is  well  under  the  anesthetic  the 
abdomen  is  prepared  for  the  operation  by  again  scrub- 
bing with  sterile  soap  and  water,  washing  with  a 
bichlorid  solution  and  then  with  sterile  normal  salt 
solution.  A  piece  of  sterile  gauze  is  placed  over  the 
area  to  be  operated  upon  and  the  surrounding  parts 
covered  with  towels  wrung  out  of  an  antiseptic  solution, 
such  as  i :  iooo  bichlorid  of  mercury.  The  temperature 
of  the  room  should  be  about  8o°  Fahrenheit. 

The  Operation. — The  patient  is  placed  in  the  Tren- 
delenburg posture,  with  the  hips  elevated  from  fifteen 
to  thirty  degrees. 

The  incision  is  usually  made  in  the  median  line 
between  the  umbilicus  and  symphysis  pubis.  A  short 
incision  is  made  at  first,  cutting  the  layers  down  to  the 
subperitoneal  fat.  This  is  picked  up  with  forceps  and 
incised,  exposing  the  peritoneum.     All  bleeding  por- 


ABDOMINAL    SECTION.  43  I 

tions  should  be  secured  and  tied  before  opening  the 
peritoneum.  The  peritoneum  is  then  picked  up  with 
forceps  and,  being  sure  that  it  is  free  from  the  viscera, 
a  small  opening  is  made  with  the  knife  or  scissors.  A 
grooved  director  is  inserted  and  the  opening  enlarged 
sufficiently  to  introduce  the  index  and  middle  fingers 
of  the  left  hand,  and  the  incision  then  enlarged  to  the 
desired  extent  by  cutting  with  a  probe-pointed  bis- 
toury. Use  broad  retractors  and  a  good  light  to  ob- 
tain efficient  observation  of  the  field  of  operation. 
The  abdomen  is  now  ready  to  carry  out  the  operation 
indicated. 

After  the  completion  of  the  operation  and  before 
closing  the  incision  in  the  abdomen,  the  hips  are 
lowered  from  the  Trendelenburg  posture  to  observe  if 
hemostasis  is  complete.  All  bleeding  points  within  the 
abdomen  must  be  ligated  and  all  oozing  arrested. 
Remove  all  blood  and  clots  by  gently  wiping  with 
sterile  gauze  sponges. 

Irrigation  is  unnecessary  except  in  infected  cases 
in  which  it  is  done  with  normal  salt  solution  at  a  tem- 
perature of  112°  F. 

Closure  of  the  Incision. — In  closing  the  abdomen  it  is 
desirable  to  use  a  method  which  will  give  a  firm  union 
and  which  will  stand  the  strain  of  an  epileptic  seizure 
should  one  occur  during  the  healing  process  or  after- 
ward. 

The  best  method  for  this  is  the  one  which  unites 
the  corresponding  layers  separately  in  the  relation  in 
which  they  existed  before  the  operation.  By  this 
method  the  peritoneum  is  closed  with  a  continuous 
suture  of  fine  catgut,  all  air  being  expelled  from  the 
abdomen  before  tying  the  suture.  The  wound  is  now 
cleaned  with  hydrogen  peroxid.  The  edges  of  the  cut 
fascia  or  muscles  are  brought  together  and  held  by 
mattress  sutures  of  silver  wire  or  silkworm  gut  placed 
about  two  inches  apart.     The  spaces  between  these 


432         THE    SURGICAL    TREATMENT    OF    EPILEPSY. 

are  accurately  united  with  interrupted  catgut  sutures. 
The  subcutaneous  fat  and  the  skin  is  closed  with  con- 
tinuous catgut  sutures. 

The  line  of  the  incision  is  now  disinfected  with 
peroxid  of  hydrogen,  dried  with  sterile  compresses, 
dusted  with  aristol,  and  covered  with  gauze  compresses 
held  firmly  in  place  by  adhesive  strips.  Over  all  this 
a  large  pad  of  gauze  and  absorbent  cotton  is  held  in 
place  by  an  abdominal  binder  which  is  accurately 
fitted  and  fastened  with  pins.  The  lower  edge  of  the 
binder  is  prevented  from  slipping  up  by  perineal  straps 
on  each  side. 

The  dressings  are  removed  about  the  tenth  or 
twelfth  day  in  uncomplicated  cases,  while  the  patient 
should  be  kept  in  bed  at  least  four  weeks  after  the 
operation. 

An  abdominal  supporter  should  be  worn  for  several 
months  after  the  patient  leaves  her  bed,  for  fear  the 
strain  of  an  epileptic  seizure  might  weaken  the  scar. 

Drug  Treatment  after  the  Operation. — It  is  important 
to  keep  the  patient  quiet  after  the  operation  and  to 
prevent,  if  possible,  any  epileptic  seizures  during  the 
repair  of  the  wound. 

The  bromids  which  were  given  before  the  opera- 
tion, should  be  continued  now  in  slightly  increasing 
doses,  and  in  sufficient  amount  to  control  the  attacks. 
Following  the  operation  they  may  be  given  by  enema 
until  the  stomach  regains  its  balance. 

After  the  wound  is  firmly  united  the  bromids  may 
be  reduced,  but  should  not  be  entirely  cut  off  for 
several  months. 

Results  of  the  Operation. — The  results  of  the  opera- 
tion, so  far  as  essential  epilepsy  is  concerned,  will  be 
disappointing  in  the  majority  of  cases.  In  proportion 
to  the  degree  that  diseased  abdominal  conditions  in- 
fluenced the  attacks,  the  better  will  be  the  results. 
If,  in  any  case,  such  irritation  was  the  sole  cause  of 


ABDOMINAL    SECTION.  433 

the  epilepsy,  the  correction  of  this  may  entirely  relieve 
the  disease.  Unfortunately  the  causes  of  essential 
epilepsy  are  very  rarely  found  where  surgical  inter- 
vention can  correct  it,  and  although  the  patient  may 
improve  as  a  result  of  relieving  an  irritation  within 
the  abdomen,  the  epilepsy  still  exists,  with  one  less 
irritable  point  to  modify  its  character  and  frequency. 

Hysterectomy  with  Removal  of  the  Ovaries  and 
Tubes. — An  incision  from  four  to  eight  inches  in  length 
is  made  in  the  median  line  between  the  umbilicus  and 
the  symphysis  pubis.  Slight  adhesions  are  broken 
up  with  the  fingers;  the  denser  ones,  by  careful  dis- 
section with  the  knife  or  scissors.  The  dense  adhe- 
sions are  best  broken  up  by  working  from  below, 
beginning  on  the  side  least  adherent,  after  tying  the 
ovarian  and  uterine  arteries. 

The  uterus  is  lifted  forward  and  to  one  side,  putting 
the  opposite  broad  ligament  on  the  stretch,  and  the 
ovarian  vessels  of  this  side  are  ligated  at  the  outer 
end  of  the  broad  ligament.  A  second  ligature  or  a 
clamp  is  placed  about  these  vessels  near  the  uterus 
and  the  vessels  divided  between  the  ligatures. 

The  round  ligament  of  the  same  side  is  next  divided 
after  tying  two  ligatures  near  the  uterus  and  cutting 
between  these. 

An  incision  is  now  made  from  one  round  ligament 
to  the  other  by  cutting  along  the  line  where  the  peri- 
toneum is  reflected  from  the  anterior  surface  of  the 
uterus  to  the  bladder. 

The  anterior  surface  of  the  uterus  below  this  line 
of  incision  is  stripped  of  its  peritoneum  by  pushing  it 
down  with  sponges  held  in  artery  forceps,  until  the 
cervix  is  well  exposed. 

The  uterine  vessels  of  this  side  are  next  ligated  close 

to  the  cervix  and  cut  above  the  ligature,  the  uterine 

end  being  held  with  forceps.  ,  The  cervix  is  cut  through 

just  above  the  vaginal  junction,  and  as  soon  as  the 

28 


434         THE    SURGICAL    TREATMENT    OF    EPILEPSY. 

cervical  canal  is  cut  a  plug  of  cotton  or  gauze  is  in- 
serted in  it. 

The  cervix  is  completely  cut  through  and  the 
uterus  pulled  to  the  opposite  side,  exposing  the  uterine 
vessels  which  have  not  been  divided.  These  are 
clamped  with  artery  forceps  and  divided  above  the 
clamp.  Next,  the  ovarian  vessels  of  this  side  are 
clamped  and  cut  and  the  uterus  and  its  appendages 
completely  removed. 

The  uterine  and  ovarian  vessels  which  are  held  by 
clamps  and  all  bleeding  points  within  the  wound 
should  be  securely  ligated. 

The  cervical  canal  is  disinfected  with  peroxid  of 
hydrogen,  and  the  stump  of  the  cervix  is  closed  over 
the  canal  by  catgut  sutures  uniting  the  anterior  and 
posterior  edges  over  the  top  of  the  canal. 

The  cut  margins  of  the  peritoneum  surrounding  the 
wound  are  next  brought  together  and  united  with  a 
continuous  suture  of  catgut,  thus  covering  the  entire 
wound  area  with  the  peritoneum. 

All  blood  and  clots  must  be  removed  from  the  peri- 
toneum by  wiping  with  gauze  sponges,  and  the  incision 
in  the  abdomen  closed. 

Salpingo-oophorectomy. — An  incision  from  two  to 
three  inches  long  is  made  in  the  median  line,  the  lower 
end  of  the  incision  reaching  about  two  inches  above 
the  symphysis  pubis. 

The  ovary  and  tube  are  drawn  out  of  the  incision 
by  means  of  the  index  and  middle  fingers. 

A  silk  ligature  is  passed  through  the  outer  portion 
of  the  broad  ligament  below  the  ovarian  vessels  and 
tied  over  the  top  of  the  infundibulo-pelvic  ligament, 
external  .to  the  fimbriated  extremity  of  the  tube. 
Another  silk  ligature  passes  through  the  uterine  end  of 
the  broad  ligament  to  secure  the  uterine  vessels  and 
is  tied  over  the  top  of  the  broad  ligament  close  to  the 
uterus.     The  utero-ovarian  ligament  is  next  ligated. 


ABDOMINAL    SECTION.  435 

The  entire  ovary  and  tube  are  removed  by  cutting 
about  half  an  inch  from  the  ligatures. 

As  an  additional  safeguard  against  hemorrhage,  the 
cut  ends  of  the  vessels  in  the  pedicles  may  be  drawn 
out  with  artery  forceps  and  a  separate  catgut  ligature 
applied  to  each  one,  or  an  additional  ligature  may  be 
tied  around  the  pedicle. 

After  all  hemorrhage  has  been  controlled  the  abdom- 
inal incision  is  closed. 

RESULTS  IN  NINE  CASES  OF  OOPHORECTOMY.* 

Case  I. — A.  B.,  age  twenty- three  years.  Family 
history  negative.  Epilepsy  at  nineteen  years;  type, 
petit  mat.  Frequent  attacks  of  major  hysteria  prior 
to  operation.  No  epileptic  attacks  for  fourteen 
months  before  operation.  Right  ovary  hypertrophied 
and  cystic;  left,  hypertrophied.  Both  tubes'  and 
ovaries  removed.  Result,  surgically  good.  No  at- 
tacks of  any  kind  from  the  time  of  operation,  Feb- 
ruary 2,  1902,  until  her  discharge,  November  14,  1902, 
a  period  of  nearly  nine  months.  Marked  improve- 
ment in  general  physical  condition  and  in  disposition. 

Case  II. — D.  S.,  age  twenty-one  years.  Father 
alcoholic.  Epilepsy  at  thirteen  years;  type,  grand 
mal.  Frequency  of  attacks  before  operation,  ten  in 
sixteen  months.  Operation  on  February  26,  1902. 
Old  pelvic  peritonitis.  Both  ovaries  adherent;  left 
could  not  be  removed ;  right,  hypertrophied  and  cystic ; 
removed.  Result,  surgically  good.  She  had  twelve 
attacks  in  sixteen  months  following  operation.  Gain 
in  weight  and  marked  improvement  in  general  health ; 
no  change  in  epilepsy. 

Case  III. — T.  C.  A.,  age  nineteen  years.  Paternal 
grandfather  alcoholic,  cousin  epileptic.  Assigned  cause 
of  epilepsy,  diphtheria.  Type,  grand  mal.  Frequency 
before  operation,  two  attacks  in  twelve  months.  Oper- 
ation on  April  25,  1902.  Both  ovaries  enlarged  and 
cystic ;  both  removed.  Result,  surgically  good.  She 
had  six  attacks  in  twelve  months  following  the  opera- 
tion.    General  condition  greatly  improved. 

♦From  the   "Craig  Colony  Hospital  Records." 


436         THE    SURGICAL    TREATMENT    OF    EPILEPSY. 

Case  IV.- — L.  B.,  age  twenty-two  years.  Sister 
hysterical.  Assigned  cause  of  epilepsy,  "ovarian 
irritation";  type,  grand  mat.  Relative  frequency  of 
attacks  before  operation,  sixty-nine  in  four  months. 
Operation  on  September  20,  1902.  Chronic  pelvic 
peritonitis.  Both  ovaries  hypertrophied ;  both  tubes 
and  ovaries  removed.  Result,  surgically  good.  She 
had  sixty-six  attacks  in  ten  months  following  the 
operation.     Attacks  much  diminished  in  frequency. 

Case  V.—C.  B.,  age  thirty-one  years.  Mother  had 
puerperal  insanity.  Assigned  cause  of  patient's  epi- 
lepsy, onset  of  menstruation  at  fifteen  years;  type, 
grand  mat  and  petit  mal.  Frequency  before  opera- 
tion, thirteen  attacks  in  nine  months.  Operation  on 
September  30,  1902.  Both  ovaries  enlarged.  Result, 
improvement  in  general  condition.  She  had  four 
attacks  in  seven  months.  The  patient  passed  from 
observation  at  the  end  of  that  time. 

Case  VI. — M.  F.,  age  twenty-eight  years.  Mother 
epileptic ;  sister  insane  and  also  epileptic.  Assigned 
cause,  onset  of  menstruation  at  thirteen  years;  type, 
grand  mat;  frequency  of  attacks  before  operation,  one 
or  two  each  month.  Operation  on  December  9,  1902. 
Left  ovary  enlarged.  Both  tubes  and  ovaries  removed. 
Result,  no  change  in  epilepsy.  She  has  had  one  attack 
each  month  since  the  operation.  Some  physical  im- 
provement. 

Case  VII. — This  case  is  not  included,  as  the  patient 
died  of  shock  following  the  operation. 

Case  VIII.— N.  J.,  age  twenty-nine  years.  Family 
history  negative.  No  assigned  cause  of  epilepsy; 
onset  at  twelve  years;  type,  grand  mal.  Frequency 
of  attacks  before  operation,  five  in  four  months. 
Operation  on  March  9,  1903.  Old  pelvic  peritonitis. 
Peritoneum  greatly  thickened.  Ovaries  adherent; 
right  ovary  enlarged ;  left,  atrophied  and  not  removed. 
Result,  surgically  good.  She  had  eight  attacks  in  four 
months  after  the  operation.     No  material  change. 

Case  IX. — Age  twenty-four  years.  Family  history 
negative.  No  assigned  cause;  type,  grand  mal; 
onset  at  twelve  years.  Frequency  of  attacks  before 
operation,  none  for  five  months.  Operation  on  May 
6,  1903.     Result,  surgically  good.     Unsatisfactory  two 


ABDOMINAL    SECTION.  437 

months   later   so   far   as   attacks  are    concerned,   the 
patient  having  had  two  within  that  time. 

Omitting  the  seventh  case,  in  which  death  followed 
the  operation,  the  average  length  of  time  that  elapsed 
after  the  operation  and  before  results  were  noted, 
was  nine  months  and  nineteen  days.  Results:  The 
attacks  were  reduced  in  frequency  in  Cases  I  and  IV. 
The  general  physical  condition  was  improved  in  Cases 
I,  II,  III,  V,  and  VI,  without  visible  improvement 
in  the  epilepsy.  In  Case  VIII  there  was  no  change 
worthy  of  note  four  months  after  operation.  In  Case 
IX  there  was  an  increase  in  the  number  of  seizures 
after  the  operation. 

As  a  general  rule — one  subject  to  modification  in 
especial  cases — operations  on  epileptic  women  for 
the  removal  of  the  reproductive  organs  may  be  done 
if  the  attacks  came  on  about  puberty  in  the  first 
instance,  and  occurred  thereafter  in  close  conjunction 
with  the  menstrual  epoch,  either  singly  or  in  small 
series,  as  is  often  the  case;  and  they  are  apt  to  give 
most  satisfactory  results  where  hereditary  causes  are 
eliminated,  and  where  the  disease  after  years  of  action 
has  failed  to  appreciably  impair  the  faculties  of  the 
mind. 


CHAPTER  XVI. 
THE  PSYCHOLOGIC  ASPECTS  OF  EPILEPSY. 

Paroxysmal  Mental  States.  Psychic  Epilepsy.  Automatism.  Pre-  and 
Post-paroxysmal  Insanity.  Transitory  Ill-humor.  Emotional  Irritability. 
Impulsiveness.  Moral  Anergia.  Feeble-mindedness.  Imbecility.  Idiocy. 
Dementia.  Manic-depressive  States.  Degrees  of  Mental  Impairment  and 
Responsibility  in  Each.  Genius  and  Epilepsy.  Moral  Decadence.  Epi- 
lepsy and  Crime. 

At  the  outset  we  may  lay  down  certain  almost 
axiomatic  facts  pertaining  to  the  effects  of  epilepsy 
on  the  mind,  in  the  main  as  follows : 

i.  Every  true  epileptic  convulsion  destroys  or 
impairs  the  integrity  of  the  mental  faculties  to  some 
extent. 

2.  Such  effects  cannot  be  measured  by  the  degree 
of  motor  or  psychic  violence  that  accompanies  the 
attack. 

There  are  convulsions  in  which  mental  activity  is 
completely  effaced — all  responsibility  in  abeyance 
during  the  progress  of  the  attack — yet  in  which  there 
is  not  the  least  perceptible  trace  of  muscular  com- 
motion in  any  part  of  the  body. 

This  is  especially  true  of  psychic  epilepsy,  which 
constitutes  one  of  the  most  perplexing  and  interesting 
problems  the  medical  jurist  can  encounter. 

3.  There  is  also  a  form  of  post-paroxysmal  autom- 
atism very  similar  in  character  to  psychic  epilepsy, 
characterized  by  acts  apparently  performed  under  the 
direction  of  conscious  volition,  seemingly  logical 
and  in  perfect  sequence,  fulfilling  a  definite  purpose; 
yet  all  through  the  performance  of  them  the  patient 
is  no  more  responsible  than  if  he  were  an  inanimate 
machine.     In  this  automatic  state  all  the  functions 

438 


PAROXYSMAL    MENTAL    STATES.  439 

of  the  body,  even  that  oftentimes  of  speech,  act  in  a 
coordinate  and  natural  manner,  although  the  field  of 
conscious  life  is  a  perfect  blank. 

It  is  difficult  to  fully  realize  the  true  character  of 
this  condition.  My  own  skepticism  of  it  was  consider- 
able until  I  had  witnessed  it  in  so  many  instances  in 
which  I  felt  absolutely  assured  that  the  patient  was 
under  the  influence  of  a  morbid  psychologic  entity 
over  which  he  had  not  the  slightest  control. 

4.  In  addition  to  the  states  of  mental  vacuity  just 
described,  we  class  the  effects  of  epilepsy  on  the  mind 
in  other  ways  in  point  of  time  as  temporary,  prolonged, 
or  permanent.  The  temporary  effects  include  tran- 
sitory states  of  disturbance  that  appear  with  the  con- 
vulsion, are  inseparable  from  it,  because  they  are, 
essentially  a  part  of  it,  and  disappear  with  it. 

The  prolonged  effects  include  forms  of  disturbance 
that  precede  or  follow  the  convulsion,  lasting  variable 
lengths  of  time,  and  assuming  many  different  types, 
while  permanent  forms  of  alienation  include  all  vari- 
eties of  mental  unsoundness,  from  simple  loss  of 
memory  to  complete  epileptic  idiocy,  imbecility,  and 
dementia. 

Before  we  go  further,  and  in  order  that  we  may 
possess  as  clear  an  impression  as  possible  of  the  whole 
subject  in  a  concrete  form,  let  me  restate  the  matter 
in  this  way. 
Paroxysmal  Mental  States  Due  to  Epilepsy. 

1.  Psychic  epilepsy.  A  complete  morbid  entity 
in  itself  and  wholly  destructive  of  responsibility  so 
long  as  it  is  present. 

2.  Epileptic  automatism.  A  condition  of  mental 
vacuity  coexisting  with  natural  bodily  activity.  This 
usually  follows  severe  attacks,  though  it  may  be 
induced  by  those  of  milder  form. 

3.  Pre-  and  post-paroxysmal  mental  disturbances. 
These  are  usually  in  the  form  of  the  most  violent  and 


44-0         THE    PSYCHOLOGIC    ASPECTS    OF    EPILEPSY. 

destructive  mania,  lasting  anywhere  from  a  few  minutes 
up  to  days  or  weeks,  and  in  rare  cases  even  longer. 

4.  Paroxysmal  or  epileptic  mania.  This  is  always 
destructive  and  dangerous  in  character,  and  in  which 
the  mental  disturbance  coincides  with  the  fit.  In  cases 
in  which  it  appears  to  be  a  substitute  for  the  fit,  it 
is  known  as  the  psychic  epileptic  equivalent. 
Inter-Paroxysmal  Mental  States  Due  to  Epilepsy. 

1.  Transitory  ill-humor  and  simple  loss  of  memory 
for  recent  events ;  in  other  cases,  for  events  regardless 
of  the  time  of  their  occurrence.  To  these  we  must 
add  as  pronounced  adjuncts  of  the  epileptic's  mental 
peculiarities:  emotional  irritability,  impulsiveness, 
moral  anergia,  and  incapacity  for  any  form  of  valuable 
productive  occupation  dependent  upon  the  initiative 
in  conception  and  consecutive  activity. 

2.  Slight  clouding  or  dulling  of  the  intellect,  as  a 
whole,  which  often  becomes  more  pronounced  just 
before  the  fit. 

3.  Feeble -mindedness. 

4.  Imbecility. 

5.  Idiocy. 

6.  Epileptic  dementia. 

7.  Acute  confusional  insanity  characterized  by 
delusions,  hallucinations,  and  illusions.  The  latter 
form,  under  either  condition,  is  quite  rare.  It  is 
also  rare  in  epilepsy  to  meet  with  acute  states  of 
depression  characterized  by  painful  delusions  or  by 
suicidal  inclination  or  attempt. 

We  may  readily  group  all  the  psychoses  that  come 
under  the  seventh  heading  under  the  broadly  generic 
term  manic-depressive  insanity,  which  includes  the 
usually  recoverable  forms  of  mania,  simple  and  recur- 
rent, melancholia  simple  and  recurrent,  and  circular 
insanity,  the  latter  being  less  curable. 

While  we  seldom  meet  with  circular  insanity  (the 
folie  circulaire  of  the  French)  due  to  epilepsy  or  existing 


PSYCHIC    EPILEPSY.  441 

coincident  with  it,  we  do  find  such  cases  occasionally. 
Two  of  the  kind  have  come  under  my  observation, 
both  ending  in  permanent  dementia. 

PSYCHIC  EPILEPSY  AND  EPILEPTIC  AUTOMATISM. 

The  effect  of  psychic  epilepsy  in  cases  in  which  the 
disease  exists  for  years,  vary  greatly.  It  has  generally 
been  assumed  that  this  was  intellectually  the  most 
destructive  of  all  the  epilepsies,  but  this  is  not  true 
in  all  cases. 

Much  depends  upon  the  etiology,  but  more  upon  the 
age  at  which  it  develops  and  the  stamina  of  the  pa- 
tient. I  have  observed  that  when  it  appears  early  in 
life  in  individuals  whose  family  history  is  good  and 
whose  stamina  is  of  superior  kind,  such  attacks  may 
occur  daily  for  years  without  appreciably  affecting 
mental  integrity.  I  recall  one  case  in  particular,  that  of 
a  girl  of  seven  years  whose  seizures  appeared  from  forty 
to  sixty  times  daily  for  five  years,  when  they  began 
to  show  a  marked  decrease,  the  child  developing 
naturally  in  every  respect.  Least  of  all  was  there 
any  blunting  or  retardation  of  her  intellectual  develop- 
ment. 

In  other  cases  in  which  the  disease  is  delayed  in  its 
establishment  until  adult  life,  and  when  it  is  preceded 
by  vicious  and  unwholesome  living,  especially  alcoholic 
excesses,  it  begins  almost  immediately  to  mar  the 
refinement  of  the  psychic  life,  and  in  two  or  three 
years  destroys  it  almost  completely.  Fortunately, 
psychic  epilepsy  is  comparatively  rare.  There  is  no 
doubt,  however,  that  it  sometimes  exists  for  years  in 
an  unrecognized  form. 

It  may  be  either  diurnal  or  nocturnal  in  its  expres- 
sion, and  is  especially  apt  to  escape  notice  when  it 
occurs  only  at  night,  being  in  some  instances  mistaken 
for  somnambulism. 

"We  are  apt  to  lose  sight  of  the  fact  that  the  slightest 


442         THE    PSYCHOLOGIC    ASPECTS    OF    EPILEPSY. 

seizures  are  just  the  very  cases  in  which  consciousness 
is  prone  to  be  most  impaired  or  involved,  and  in  which 
a  seizure  is  most  likely  to  be  overlooked  by  the  friends 
or  even  the  patient  himself,  and  thus  it  happens  that  a 
paralysis  of  the  central  hierarchy  of  the  nervous  system 
may  so  withdraw  control  over  lower  centers  as  to 
issue  in  wild  excitement,  although  the  epileptic  seizure 
was  so  slight  as  to  be  scarcely,  if  at  all,  appreciable 
to  the  onlooker"  (Bevan  Lewis). 

Epileptic  Automatism.— It  is  quite  remarkable  how 
somnambulistic  individuals  unconsciously  guard  them- 
selves from  harm  while  in  such  a  state.  In  walking 
about,  they  go  with  their  eyes  closed  or  opened,  or 
partly  opened,  but  it  is  plain  to  see  that  when  the  eye 
is  open  it  does  not  see. 

Such  individuals  appear  to  act  with  deliberate  pur- 
pose, avoiding  places  that  are  dangerous  and  never 
striking  objects  that  produce  injury.  The  instinct 
of  self-preservation  seems  as  active  at  such  times  as 
under  normal  conditions.  I  am  personally  familiar 
with  several  patients  with  whom  a  rational  conversa- 
tion may  be  carried  on  while  they  are  in  an  automatic 
epileptic  state,  but  I  have  never  witnessed  a  case  in 
which  any  knowledge  of  the  conversation  could  be 
recalled  by  the  patient,  provided  the  automatism  was 
complete,  after  the  automatic  period  had  passed  away. 
It  has  been  my  observation  that  the  acts,  mannerisms, 
peculiarities,  habits  of  vocation,  and  the  like,  shown 
by  the  individual  in  his  normal  state,  can  be  carried 
over  into  and  most  perfectly  repeated  in  the  fullest 
detail  in  the  automatic  state,  but  that  it  is  impossible 
for  the  automaton .  to  carry  the  memory  of  such  acts  out 
of  this  state  into  the  conscious  state  beyond.  I  have  re- 
peatedly tested  this  point  and  have  never  found  an 
instance  in  which  it  did  not  hold  true. 

As  a  rule,  the  psychic  or  automatic  epileptic,  during 
the  access  of  the  attack,  is  not  in  a  normally  receptive 


Plate  24. 


\ 


E.  C,  who  had  40  to  60  mild  seizures  a  day  for  seven  years,  yet  whose 
mental  development  proceeded  naturally.  At  the  age  of  fourteen  years 
(her  epilepsy  began  at  seven  years)  she  was  having  a  single  attack  only 
once  in  three  to  four  months.  This  case  is  presented  to  show  that  psychic 
epilepsy  does  not  always  destroy  the  mind. 


EPILEPTIC    AUTOMATISM.  443 

condition,  so  far  as  special  sense  impressions  are  con- 
cerned. If  they  are  spoken  to,  it  must  be  done  loudly 
for  them  to  hear  and  understand,  and  it  is  often  neces- 
sary to  accompany  spoken  commands  with  a  gesture. 

Many  suffer  from  partial  deafness  at  such  times,  but 
can  readily  interpret  the  meaning  of  a  gesture,  the 
visual  apparatus  being  apparently  unimplicated  in  the 
attack. 

The  automatic  state  is  usually  one  of  motor  tran- 
quillity, though  it  may  be  the  reverse.  There  are  cases 
in  which  marked  combativeness  is  aroused  by  any 
attempt  to  exercise  control  over,  or  to  aid,  such  a 
person.  A  young  man  afflicted  in  this  way  was  riding 
on  an  elevated  train  in  New  York  when  the  guard 
noticed  that  he  appeared  ill,  and  grasped  his  arm  to 
assist  him.  The  patient  immediately  struck  at  him 
in  great  fury  and  a  violent  struggle  ensued,  ending  in 
the  arrest  of  the  patient  and  his  detention  by  the 
police,  until  he  regained  consciousness,  when  he  estab- 
lished his  claim  as  an  epileptic  and  was  permitted 
to  go. 

A  male  epileptic  had  a  psychic  seizure  of  fifteen 
minutes'  duration.  He  answered  questions  intelli- 
gently, though  I  had  to  shout  them  loudly  to  make 
him  understand.  He  sauntered  about  the  room  look- 
ing at  various  objects,  and  was  perfectly  calm  and 
rational  to  all  outward  appearances,  until  I  tried  to 
lead  him  over  to  the  light  to  examine  his  eyes.  He 
jumped  back,  assumed  a  threatening  attitude,  and 
made  as  though  he  would  strike  me.  A  little  coaxing 
finally  induced  him  to  yield,  though  it  was  easy  to  see 
that  he  was  suspicious  of  harm.  His  face  wore  a  puz- 
zled, apprehensive,  pained  expression  of  a  type  that  I 
have  never  seen  duplicated  save  in  other  epileptics 
during  the  aura  and  the  early  part  of  some  convulsions. 
Fear,  being  one  of  the  most  primitive  instincts,  appears 
to  be  retained   and  unconsciously  expressed  by  the 


444         THE    PSYCHOLOGIC    ASPECTS    OF    EPILEPSY. 

epileptic  while  in  this  state.  It  seems  to  be  the  auto- 
matic operation  of  the  law  of  self-preservation. 

One  redeeming  feature  of  psychic  epilepsy  in  its  most 
profound  form,  that  is,  when  a  single  attack  lasts  for 
hours  or  days,  is,  that  such  attacks  are  separated  by 
wide  intervals.  When  the  attacks  are  rapid  in  suc- 
cession and  consist  merely  of  momentary  "blanks," 
they  may  occur  scores  of  times  in  a  day. 

The  medicolegal  aspects  of  this  type  of  epilepsy 
depend,  so  far  as  responsibility  is  concerned,  upon  our 
ability  to  determine  the  existence  of  the  automatic 
state  at  a  given  moment.  This  may  be  difficult  to  do 
beyond  reasonable  doubt,  though  if  we  can  prove  that 
the  person  is  a  sufferer  from  epilepsy  at  the  time,  or 
ever  had  it  in  any  form,  we  can  always  create  a  reason- 
able belief  that  the  patient  may  have  acted  while  in 
a  seizure,  without  any  intent  whatever,  and  under  con- 
ditions that  should  free  him  from  responsibility. 

The  evidence  of  the  presence  of  epilepsy,  already 
presented  in  detail  in  a  previous  chapter,  needs  to  be 
carefully  studied  in  order  to  arrive  at  a  just  conclusion 
in  medicolegal  cases.  If  it  can  be  proved  beyond 
reasonable  doubt  that  the  individual  has  epilepsy,  the 
question  of  responsibility  is  not  difficult  after  that. 
We  may  not  be  able,  it  is  true,  to  say  positively  that 
he  was  under  the  influence  of  a  seizure  at  the  moment 
an  overt  act  was  committed,  while,  on  the  other  hand, 
we  are  equally  as  unable  to  prove  that  a  seizure  was 
not  present.  Psychic  convulsions  defy  all  ordinary 
methods  of  detection.  They  can  readily  be  noted, 
however,  by  one  trained  in  the  observance  of  their 
expression. 

One  of  the  strongest  points  in  clearing  the  patient 
of  responsibility  for  crime  is  the  utter  absence  of 
motive.  In  other  cases  the  apparent  motive  may  be 
out  of  all  proportion  to  the  brutality  and  degree  of 
the  crime  committed  under  the  explosive  violence  of 


Plate  25. 


P.  McS.,  photographed  while  in  a  state  of  epileptic  automatism.  The 
patient  was  unconscious  at  the  moment  the  picture  was  made,  remaining 
so  half  an  hour  afterward — this  state  following  a  severe  grand  mal  attack. 
Criminal  acts  by  epileptics  while  in  this  state  are  not  uncommon. 


EPILEPTIC    AUTOMATISM.  445 

an  epileptic  attack  that,  itself,  may  have  been  incited 
by  a  slight  provocation.  In  such  cases  it  may  be 
difficult  to  determine  the  degree  of  responsibility.  But 
it  is  always  safe  to  argue  that  every  epileptic  suffers 
from  defective  inhibition.  The  power  of  self-control, 
under  the  faintest  causes  that  challenge  it,  is  gone,  a 
fact  that  in  itself  places  the  epileptic  in  the  irresponsible 
class. 

Psychic  epileptics  may  commit  all  manner  of  crimes : 
theft,  arson,  rape,  assaults,  homicides.  They  are  not 
infrequently  pyromaniacs  entirely  without  reason  or 
impelled  by  the  flimsiest  motives. 

An  epileptic  boy  of  twelve  years,  of  fair  intelligence 
and  previous  good  conduct,  was  given  some  stockings 
to  wash  that  belonged  to  a  fellow  patient.  The  task 
displeased  him,  so  he  took  them  into  the  attic  and 
set  them  on  fire,  the  timely  discovery  of  which  pre- 
vented the  loss  of  the  building.  He  could  give  no 
reason  for  the  act,  and  expressed  regret  over  its  occur- 
rence.    His  conduct  later  was  exemplary. 

W.  E.  P.,  age  forty-four  years  on  admission.  Epi- 
leptic since  his  eighteenth  year.  He  was  a  clergyman 
by  profession,  and  was  accustomed  to  having  from 
eight  to  ten  attacks  a  month,  both  light  and  severe. 
He  began  to  wander  about  the  Colony  collecting  trash 
and  starting  fires  in  scores  of  places  on  the  same  day. 
He  would  burn  up  small  sticks,  straw,  pieces  of  paper, 
and  such  debris  wherever  he  found  it.  His  whim  was 
ignored  for  awhile,  but  later  it  was  necessary  to  place 
him  under  restraint.  He  would  never  give  any  reason 
for  doing  this,  but  it  seemed  clear  that  he  was  acting 
under  some  morbid  impulse.  He  was  of  a  paranoiac 
type,  constantly  depressed,  and  refused  ever  to  say 
that  his  health  was  good,  for  fear  "  God  would  punish 
him  with  a  seizure  for  boasting." 

People  who  suddenly  disappear  without  known 
cause  or  purpose  for  indefinite  periods  and  are  finally 


446         THE    PSYCHOLOGIC    ASPECTS    OF    EPILEPSY. 

heard  from  in  some  remote  locality,  unable  to  explain 
how  they  happen  to  be  there,  should  be  suspected  of 
being  victims  of  this  form  of  epilepsy. 

The  case  of  the  commercial  traveler  previously  men- 
tioned illustrates  this.  In  this  instance  the  man  went 
twenty-eight  days  in  a  subconscious  state,  performing 
the  most  complex  acts,  visiting  different  cities,  travel- 
ing over  many  railroads,  taking  orders  for  goods, 
writing  business  letters  complete  in  every  particular, 
and  making  full  notes  daily  in  his  diary.  During  the 
eighteen  months  I  have  known  him  he  has  had  but 
one  seizure  of  this  kind,  though  his  attacks  of  petit 
mal  are  quite  frequent  and  he  is  often  automatic  after 
them,  doing  various  things  for  half  an  hour  or  so  that 
he  has  no  knowledge  of  later. 

PRE-  AND  POST-PAROXYSMAL  EPILEPTIC  INSANITY. 

Of  the  two  conditions,  pre-  and  post-paroxysmal 
epileptic  insanity,  the  former  is  by  far  the  more 
frequent.  When  it  occurs,  it  may  develop  just- 
before  the  fit,  appearing  suddenly  in  great  violence, 
or  it  may  begin  days  before  in  an  insidious,  accumula- 
tive way,  the  first  changes  affecting  the  disposition, 
which,  usually  placid  and  even,  becomes  irritable  in 
spite  of  all  efforts  at  self-control.  Evidences  of 
irritability  increase.  The  patient  becomes  loquacious, 
finds  fault  generally,  magnifies  trifles  into  matters  of 
great  moment,  is  "touchy,"  suspicious,  discredits  the 
motives  of  all  around  him,  is  unable  to  sleep  well, 
complains  of  disturbing  dreams,  suffers  from  headache, 
appears  feverish  and  in  a  state  of  subdued  excitement, 
finally  acquiring  pronounced  falsification  of  special 
sense  perceptions.  These  take  the  widest  possible 
range,-  and  constitute  the  aura  of  an  approaching 
attack. 

Some  have  delusions  of  persecution,  others  illusions, 
while  hallucinations  of  sight  also  occur  usually  just 


EPILEPTIC    INSANITY.  447 

before  the  fit.  These  are  mostly  of  a  terrifying  nature, 
though  in  rare  cases  they  may  be  ecstatic. 

Pronounced  morbid  depression  just  before  the  fit  is 
rare,  the  mental  state  being  more  often  that  of  domi- 
nant, confused  ideation;  the  line  of  thought,  as  indi- 
cated by  the  speech,  rapidly  changing,  the  patient 
speaking  in  a  quick,  explosive  way  that  gains  in 
impulse  as  it  proceeds,  until  an  inarticulate  jargon  is 
the  result. 

Again,  the  flow  of  incoherent  ideas  may  be  less 
tumultuous,  though  more  irrational  in  character,  the 
patient  talking  the  veriest  nonsense  in  the  most  casual 
and  self-contained  way.  Others  express  fixed  insane 
ideas  in  an  insistent  way,  without  evidence  of  exalta- 
tion or  depression. 

A  man  of  thirty-five  years,  whose  infrequent  attacks 
nearly  always  left  him  with  sensory  aphasia,  calmly 
asserted  for  weeks  that  all  the  blood  had  been  extracted 
from  his  body.  Finally  I  stuck  a  pin  rather  forcibly 
into  his  finger  one  day,  when  he  was  surprised  to  see 
the  blood  flow.  He  did  not  mention  his  lack  of  blood 
again. 

Another  male  patient  of  twenty-two  years,  of  the 
finest  physique,  whose  epilepsy  followed  too  much 
riotous  living,  fancied  he  was  being  "played  on"  every 
night  by  electric  waves  sent  through  the  walls  of  his 
room  for  the  purpose.  He  suffered  from  the  idea 
acutely  just  before  his  seizures,  after  which  it  was  less 
insistent.  In  two  months  it  left  him,  and  his  attacks 
ceased  for  several  months,  only  to  recur  when  he  re- 
turned to  the  old  improper  way  of  living. 

As  a  rule,  disordered  mental  states  that  precede  the 
convulsive  periods  subside  completely  with  the  coma 
stage  that  follows  the  fit — the  acme  of  the  often  long- 
drawn-out  epileptic  state.  Some  patients  fail  alto- 
gether to  remember  incidents  that  happened  during 
the  pre-convulsive  period  of  disturbance,  which  should 
always  be  held  to  include  the  period  of  irresponsibility. 


448         THE    PSYCHOLOGIC    ASPECTS    OF    EPILEPSY. 

PAROXYSMAL  EPILEPTIC  MANIA. 

Some  grand  mat  attacks  are  accompanied  by  the 
greatest  psycho-motor  violence  that  it  is  possible  to 
conceive  of.  Such  violence  finds  no  parallel  in  intensity 
in  any  other  form  of  insanity.  The  patient  is  in  a 
state  of  the  wildest  frenzy  (epileptic  furor),  rushing 
blindly  about  in  irresponsible  rage,  striking  and  assault- 
ing every  one  he  happens  to  come  in  contact  with. 
The  more  muscular  the  patient,  the  greater  the  possible 
damage.  Such  epileptics  seem  to  develop  superhuman 
strength.  It  has,  in  fact,  been  shown  that  the  degree 
of  muscular  power  an  epileptic  may  put  forth  during 
a  seizure  is  far  in  excess  of  that  he  can  exert  in  his 
normal  state. 

I  have  demonstrated  this  by  placing  the  dynamom- 
eter in  the  patient's  grasp  during  serial  and  status 
attacks.  Patients  of  ordinary  physique,  men  and 
women,  often  show  the  most  astounding  strength 
during  the  fit,  requiring  five  or  six  strong  attendants 
to  hold  them. 

These  excessive  frenzy  states  are  generally  brief, 
rarely  lasting  more  than  a  few  minutes  up  to  half  an 
hour,  though  they  may  be  rapidly  repeated,  as  I  saw 
in  the  case  of  a  young  mechanic  who  could  only  be 
cared  for  with  reasonable  safety  for  days  at  such 
times  by  covering  the  floor  and  walls  of  his  small  room 
with  mattresses.  Such  patients  are  always  liable  to 
injury,  both  from  their  own  violent  movements,  and, 
in  rare* instances,  accidentally  through  the  well-meant 
efforts  of  others  in  trying  to  restrain  them. 

Complete  exhaustion  usually  follows  such  outbreaks, 
often  severe  enough  to  keep  the  patient  in  bed  for 
days.  ■ 

It  is  impossible  to  determine  the  proportion  of 
epileptics  who  develop  paroxysmal  mania,  but  it  may 
appear  in  almost  any  type  of  the  disease,  and  sue- 


TRANSITORY    PERIODIC    IRRITABILITY.  449 

cessive  attacks  in  the  same  patient  may  only  be  hours, 
or  again  years,  apart. 

We  come  now  to  the  more  permanent  effects  of  the 
disease  on  the  mind,  the  inter-paroxysmal  states,  which 
will  be  discussed  briefly  in  regular  order,  beginning 
with  the  milder  and  more  common  varieties  first. 

TRANSITORY  PERIODIC  IRRITABILITY. 

Through  daily  intimate  contact  with  several  hundred 
epileptics  for  a  number  of  years,  the  writer  has  had 
abundant  opportunity  for  observing  what  he  has  pre- 
viously spoken  of  as  the  temperamental  effects  of  the 
disease.  It  is  scarcely  a  morbid  entity,  unless  we  call 
sudden  unprovoked  anger,  marked  irritability,  sullen- 
ness,  or  ill-humor  morbid  entities  also.  At  any  rate, 
periodic  ill-humor  must  be  looked  upon  as  often  con- 
stituting a  distinct  forerunner  of  the  convulsive  attack 
as  well  as  being  a  result  of  it. 

Among  the  scores  of  cases  I  have  been  privileged 
to  see  almost  daily  for  years,  I  have  learned  to  detect 
with  almost  unfailing  certainty — through  noting  tem- 
peramental changes  alone  the  moment  the  patient 
enters  the  room  and  begins  to  speak — the  approach  of 
a  convulsion  a  few  hours  or  even  days  in  advance  of 
the  convulsive  period.  An  almost  imperceptible 
change  in  personality  has  been  wrought.  The  patient 
is  querulous,  fussy,  fault-finding,  nothing  goes  right; 
trifles  that  ordinarily  produce  no  effect  on  him  now 
completely  engage  his  attention.  His  friends  ignore 
him,  his  family  is  indifferent  to  his  needs  and  his  con- 
dition, his  fellow  patients  are  no  longer  congenial, 
their  attacks  disturb  him,  he  cannot  endure  their 
jocose  remarks,  distorting  them  into  expressions  of 
ridicule.  Finally,  these  ideas  may  persist  in  their 
growth,  looming  up  larger  and  larger  on  the  horizon 
of  a  morbidly  heated  mind,  until  they  pass  into  quali- 
fied delusions,  all  being  dependent  upon  the  subtle, 
29 


450         THE    PSYCHOLOGIC    ASPECTS    OF    EPILEPSY. 

pernicious,  autocratic  influence  of  the  approaching 
attack,  and  all  completely  disappearing,  as  if  by 
magic,  after  the  attack  is  over.  In  some  cases,  as  we 
have  stated,  these  ill-humor  periods  begin  a  day  or  so 
only  before  the  fit,  in  others  they  come  on  weeks  before, 
while  in  still  other  rare  instances  they  come  and  go, 
without  the  occurrence  of  a  seizure,  being,  as  it  were, 
a  long-drawn-out,  silently  discharging  seizure— a  fit 
without  a  climax. 

It  is  difficult  to  estimate  accurately  the  proportion 
of  epileptics  who  manifest  to  some  extent  these  tem- 
peramental obliquities  dependent  upon  the  seizure 
periods,  but  it  is  entirely  within  reason  to  place  it  as 
high  as  from  75  per  cent,  to  80  per  cent,  or  more. 

Memory. — Of  all  the  mental  faculties  the  memory 
in  epilepsy  is  the  first  to  suffer,  though  we  cannot  say 
that  it  does  so  permanently  in  every  case.  Much 
depends  upon  the  frequency,  type,  and  severity  of  the 
attack — more  upon  the  type  than  anything  else.  In 
motor  epilepsy  the  attacks  may  be  repeated  weekly  or 
daily  for  years,  with  scarcely  any  appreciable  loss  of 
memory.  In  other  cases  of  greater  psychic  involve- 
ment with  corresponding  loss  of  motor  disorder,  the 
memory  is  affected  early  and  in  a  marked  degree, 
while  in  epileptic  dementia,  idiocy,  and  imbecility  it 
is  substantially  completely  destroyed. 

I  have  repeatedly  observed  that  a  single  seizure 
destroyed  the  memory  of  a  thing  an  individual  was 
especially  charged  not  to  forget.  A  skilled  mechanic 
was  sent  to  a  neighboring  village  on  an  errand.  Half- 
way there  he  had  a  mild  seizure  that  left  him  auto- 
matic for  a  few  moments.  When  consciousness  was 
restored  he  was  totally  unable  to  recall  the  purpose 
of  his  errand,  and  had  not  done  so  an  hour  later 
when  he  was  reminded  of  it.  In  the  meantime,  he 
appeared  perfectly  rational  in  every  respect. 

An  epileptic  carpenter  was  instructed  to  make  a 


TRANSITORY    PERIODIC    IRRITABILITY.  45 1 

simple  piece  of  furniture  from  a  drawing  made  in  his 
presence  at  eight  o'clock  in  the  evening.  He  studied 
the  drawing  with  great  care  at  the  time.  Early  the 
following  morning  he  had  a  seizure,  and  on  being  ques- 
tioned later,  had  forgotten  the  proposed  work  as  com- 
pletely as  though  it  had  never  been  mentioned  to  him. 
Finally  the  drawing  was  produced,  when  he  at  once 
exclaimed,  "Ah!  that's  it;  I  remember  it  all  now!" 

The  fact  that  isolated  seizures  destroy  recent  mem- 
ory impressions  makes  it  difficult  to  teach  epileptics 
under  purely  intellectual  systems.  A  maximum  of 
reiteration  is  required  often  with  a  minimum  of  results. 

In  determining  the  disintegrating  effects  of  epilepsy 
on  the  memory,  we  must  guard  against  mistaking  the 
effects  of  the  bromids  in  this  respect  for  those  of  the 
disease.  It  was  almost  a  matter  of  daily  occurrence ( 
a  few  years  ago,  to  admit  patients  to  the  Craig  Colony 
whose  mental  bromism  was  so  pronounced  as  to  re- 
semble acute  dementia. 

When  memory  impairment  becomes  fixed,  a  con- 
tinuous dulling  or  clouding  of  the  intellect  is  observed. 
The  patient  habitually  forgets,  loses  all  conception  of 
time,  becomes  incapable  of  performing  duties  exacting 
in  execution  as  to  time,  and  demands  constant  urging 
and  stimulation  to  endeavor. 

The  establishment  of  this  condition  foreshadows  the 
beginning  of  f eeble-mindedness,  a  state  into  which  fully 
50  per  cent,  of  all  epileptics  sooner  or  later  fall.  It  is 
not  so  much  a  condition  of  helplessness  as  one  in 
which  the  individual  does  better  under  some  direction 
and  control  than  without  it.  With  the  approach  of 
the  paroxysmal  period,  this  condition  is  heightened 
in  intensity,  to  become  again  less  marked  as  such 
period  recedes. 

The  next  grade  in  mentality  below  that  of  feeble- 
mindedness reached  by  many  epileptics  is  imbecility, 
a  condition  less  frequent  than  the  former. 


452         THE    PSYCHOLOGIC    ASPECTS    OF    EPILEPSY. 

The  imbecile  is  usually  unable  to  receive  many 
impressions,  or  to  grasp  and  make  use  of  daily  experi- 
ences. Individual  and  insignificant  elements  make  up 
the  sum  of  their  experience.  According  to  Buccolo, 
thought  with  them  is  retarded — a  more  difficult  propo- 
sition to  prove  than  is  the  fact  that  it  is  scanty  and 
along  the  most  elemental  lines.  Judgment  is  almost 
wholly  lacking.  When  present,  it  is  defective  and 
necessarily  rarely  based  on  experience,  though  it  pre- 
supposes the  presence  of  memory,  which  is  feebly  pos- 
sessed, except  in  individual  cases  of  imbecility,  even  by 
those  of  the  higher  grades. 

Consciousness  is  generally  but  little  impaired,  while 
memory  for  all  but  the  most  recent  events  is  lacking. 
Occasionally  trifling  incidents  are  permanently  remem- 
bered, while  notable  ones  are  forgotten. 

The  imbecile's  knowledge  of  life  is  small;  his  world 
contracted  and  narrow ;  and  he  measures  its  influences 
and  events  largely  by  the  manner  in  which  they  im- 
press his  personality.  The  ego  is  magnified.  He 
lacks  stamina  or  reserve  force  of  any  kind,  and  under 
extraordinary  conditions  he  is  wholly  incapable  of 
acting  with  salutary  discretion. 

The  state  of  imbecility  is  often  accentuated  by 
epileptic  crises  and  may  be  complicated  with  some 
show  of  violence.  Not  infrequently  it  antedates  the 
epilepsy,  occupying  to  some  extent  the  position  of 
cause,  though  more  often  it  follows  it.  Epileptic  im- 
beciles, without  exception,  are  mentally  incompetent 
under  the  medical  test  of  responsibility.  Some,  how- 
ever, are  shrewd  enough  to  utilize  their  little  knowledge 
in  a  manner  to  give  their  acts  and  assertions  so  fair  a 
semblance  of  sanity  and  accuracy  that  they  may  be 
accepted  as  true  by  the  layman  or  under  legal  defini- 
tions of  responsibility.  It  is  to  be  regretted  that  they 
are  not  always  judged  from  a  medical  standpoint 
alone. 


Plate  26. 


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TRANSITORY    PERIODIC    IRRITABILITY.  453 

Epileptic  idiocy  is  the  lowest  mental  state  the  epilep- 
tic can  acquire,  save  that  of  epileptic  dementia.  In 
either  case  there  is  virtually  a  total  loss  of  the  faculty 
of  thought. 

This  condition  may  be  congenital  or  acquired,  and, 
like  epileptic  imbecility,  may  stand  as  a  cause  of  the 
epilepsy  in  part,  or  as  the  result  of  the  convulsions. 
Its  causes,  as  shown  by  the  results  of  autopsies,  in- 
clude chronic  encephalitis,  diffuse  or  circumscribed ; 
diffuse  syphilitic  disease  of  the  blood-vessels ;  arrest  of 
vascular  development  in  the  cortex ;  irregularity  in  the 
two  hemispheres ;  inequality  in  the  peripheral  cortical 
layer  on  the  two  sides ;  defect  of  the  third  frontal  con- 
volution and  the  Island  of  Reil;  meningo-encephalitis, 
with  thickening  and  adherence  of  the  pia  and  brain, 
such  as  may  occur  after  forceps  and  trauma;  cephal- 
hematoma internum;  spontaneous  hemorrhages;  em- 
bolism from  heart  disease;  thrombosis  from  cholera 
infantum,  followed  by  destruction  of  cortical  cells  and 
atrophy  of  the  cortex;  macrocephalus  and  micro- 
cephalus.  Any  of  these  causes  acting  in  conjunction 
with  the  disastrous  effects  of  severe  and  prolonged 
epileptic  seizures  suffice  to  produce  epileptic  idiocy. 

Premature  ossification  of  the  cranial  suture  is  no 
longer  so  much  regarded  as  a  cause  of  idiocy,  nor  can 
we  say  that  it  alone  is  ever  the  cause  of  epilepsy, 
though  its  contributory  effects  may  not  be  denied. 

The  epileptic  idiot  is  usually  small  in  stature  and 
often  dwarfish  in  appearance.  He  is  generally  unde- 
veloped, the  countenance  is  childish,  the  hair  on  the 
face,  pubes,  and  other  parts  of  the  body  is  either 
absent,  scanty,  or  excessive;  the  reproductive  organs 
are  undeveloped;  the  menstrual  function  is  absent, 
late,  or  irregular;  the  teeth  are  backward  in  eruption 
and  faulty  in  arrangement ;  the  palate  is  asymmetrical. 
All  the  special  senses  are  blunted.  The  deep  and 
superficial  reflexes  may  be  either  lost  or  increased. 


454         THE    PSYCHOLOGIC    ASPECTS    OF    EPILEPSY. 

There  is  usually  incoordination  or  paralysis  of  the 
lower  extremities.  Irregular  movements  of  the  eyes, 
and  nystagmus  are  common.  There  is  stuttering, 
halting,  or  otherwise  imperfect  speech. 

The  anatomic  stigmata  of  degeneration  are  found  in 
80  per  cent,  of  all  cases,  including  anomalies  of  the 
eyes,  ears,  mouth,  nose,  and  especially  the  bones  of 
the  face,  while  30  per  cent,  of  all  idiots  suffer  from 
epilepsy  (Wildermuth) . 

These  degenerate  physical  distinctions  alone  largely 
indicate  the  type  of  mentality  we  should  expect  to 
find  associated  with  this  condition.  Intellectually, 
idiots  bear  some  class  division,  being  separable  for 
educational  purposes  into  high  and  low  grades.  It  will 
serve  our  purpose,  however,  at  this  time  to  consider 
them  in  a  single  group,  since  we  refer  to  epileptic 
idiots  only,  all  of  whom  belong  permanently  to  the 
irresponsible  and  unteachable  class. 

As  a  rule,  they  are  wholly  unable  to  comprehend 
their  surroundings;  possess  no  knowledge  of  their 
environment  and  manifest  no  interest  in  it,  no  matter 
how  often  or  how  radically  it  may  change.  They  have 
no  degree  of  self-consciousness ;  can  form  no  judgment 
respecting  the  simplest  matters;  invariably  ignore 
calls  of  the  emunctories,  soiling  themselves  habitually. 
They  are  absolutely  indifferent  to  personal  appearance. 

They  show  no  evidence  of  emotional  life,  save  per- 
haps slight  vacillation  in  their  general  feelings ;  rarely 
show  any  excitability  or  evince  any  feeling  of  pain, 
fear,  or  pleasure ;  they  are  wholly  ignorant  of  the  laws 
of  self-preservation,  save  that  of  body  sustenance,  and 
even  that  is  sometimes  lost. 

Epileptic  idiocy  is  most  frequently  met  with  in  the 
young,  generally  under  the  age  of  ten  years,  and  rarely 
arises  de  novo  after  the  eighteenth  or  twentieth  year. 
Its  prototype  after  that  period  is  found  in  epileptic 
dementia,  which  may  develop  at  any  age,  though  it  is 


Plate  27. 


3  £ 


If 


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o  „ 
<■  ° 


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3  £ 


TRANSITORY    PERIODIC    IRRITABILITY.  455 

most  common  in  young  and  middle  adult  life.  Like 
the  epileptic  imbecile,  the  epileptic  idiot  essentially 
belongs  to  the  wholly  irresponsible  class. 

Epileptic  Dementia. — The  epilepsies  that  remain  con- 
fined in  their  origin  during  attacks  and  throughout  the 
greater  part  of  their  manifestations  to  the  motor  side, 
seldom  reduce  the  mental  faculties  to  the  extent  of 
their  complete  destruction.  This  is  especially  true  of 
Jacksonian  epilepsy  and  other  forms  in  which  the  con- 
vulsion, while  motor,  may  be  general.  Many  fits  of 
the  latter  kind  leave  the  psychic  life  in  perfect  integrity 
the  moment  the  fit  is  over. 

The  forms  of  convulsions  that  appear  to  have  their 
origin  in  the  frontal  lobes — in  the  "  organs  of  the  mind" 
—and  those  followed  by  more  or  less  prolonged  periods 
of  automatism,  or  deep,  prolonged  coma,  may  induce 
complete  epileptic  dementia  in  favorable  subjects  in 
two  or  three  years'  time. 

It  has  repeatedly  been  observed  in  the  most  pro- 
nounced cases  of  dementia,  that  the  epileptic  paroxysm 
may  temporarily  stimulate  morbid  mental  commotion, 
with  the  result  that  the  long  period  of  sluggish  apathy 
is  broken,  the  patient  becomes  excited,  violent,  and 
dangerous,  and  is  especially  prone  just  then  to  commit 
murderous  assaults.  This  tendency  stamps  the  epilep- 
tic dement  as  a  dangerous  factor  at  any  moment. 
His  frenzy  appears  as  a  flash,  spends  itself  in  a  furious 
psychomotor  storm,  and  disappears  as  quickly  as  it 
came. 

Ordinarily  he  is  quiet,  obedient,  innocent  of  harm, 
and  plastic  under  control,  but  when  the  brutal  (Hugh- 
lings-Jackson)  expenditure  of  nervous  force  is  suddenly 
displayed  he  is  changed  into  an  impulsive  madman, 
ready  to  attack  without  motive  or  justification,  and 
capable  of  committing  the  most  atrocious  crimes. 

Epileptic  dementia  is  rare  during  the  senile  epoch, 
its  victims  generally  being  between  the  ages  of  twenty 


456         THE    PSYCHOLOGIC    ASPECTS    OF    EPILEPSY. 

and  forty  years.  It  is  essentially  incurable  and  tends 
to  shorten  life.  Elsewhere  we  have  called  attention  to 
the  fact  that  the  average  age  at  death  in  220  cases  was 
twenty-nine  years. 

Manic-depressive  states  include  the  acute  recoverable 
psychoses,  mania,  and  melancholia,  under  both  simple 
and  complex,  and  circular  insanity.  It  is  therefore 
a  group  term  used  to  designate  the  wide  range  of 
symptoms  characteristic  of  mania  and  melancholia,  and 
in  which  leading  symptoms  vary  so  greatly  as  to  lead 
occasionally  to  considerable  confusion. 

Transitory  epileptic  mania  is  characterized  by  great 
psychomotor  excitement ;  a  purposeless  activity ;  great 
destructiveness ;  a  happy,  though  excessively  emo- 
tional, attitude;  unsystematized  delusions;  occasion- 
ally hallucinations ;  and,  rarely,  some  dimming  of  con- 
sciousness, though  usually  the  perceptive  faculties  are 
more  than  ordinarily  acute. 

The  depressive  forms  are  characterized  by  a  diminu- 
tion or  loss  of  psychomotor  activity,  a  lack  of  spon- 
taneous bodily  exertion;  a  paucity  of  ideas;  an  emo- 
tional attitude  indicative  of  great  dejection;  a  tense, 
drawn,  apprehensive  expression;  prominent  delusions, 
usually  of  the  persecutory  type,  and  some  obscuration 
of  consciousness.  In  some  cases  the  two  states  alter- 
nately appear  in  the  same  individual,  and  it  is  now 
generally  conceded  that  they  are  phases  of  but  one 
disease  process.  At  the  same  time,  the  constant  re- 
currence of  definite  fundamental  symptoms  all  in  one 
attack,  the  uniformity  of  their  behavior  in  course  and 
outcome,  the  occasional  intimate  relation  of  different 
forms  of  the  same  disease,  where  one  form  merges 
slowly  or.rapidly  into  another,  has  led  to  the  conclusion 
that  all  may  be  definitely  classified  under  the  three 
heads  given,  namely:  manic,  depressive,  and  mixed. 

The  two  former  are  nearly  always  accentuated  at 
the  period  of  epileptic  discharge  which  brings  to  light 


Plate  28 


A  case  of  partial  epileptic  dementia,  characterized  by  extreme  good 
nature  instead  of  marked  epileptic  irritability,  so  common  after  years  of 
the  disease. 


Plate  29. 


A  case  of  epileptic  dementia,  analogous  in  all  respects  to  terminal  de- 
mentia following  ordinary  forms  of  mental  diseases,  except  that  marked 
maniacal  periods  are  apt  to  precede  or  follow  the  epileptic  attack. 


TRANSITORY    PERIODIC    IRRITABILITY.  457 

smouldering  manifestations  not  hitherto  suspected  as 
being  present.  This  feature  is  more  noticeable  in  the 
manic  than  in  the  depressive  forms. 

States  of  transitory  exaltation  are  common,  though 
they  rarely  become  chronic  in  epilepsy ;  while  states  of 
depression  marked  by  suicidal  intent  are  distinctly 
uncommon. 

In  the  writer's  experience,  in  the  care  of  some  1600 
cases  during  a  period  of  fifteen  years,  in  200  of  which 
the  patients  were  under  judicial  commitment  as  insane, 
he  recalls  but  two  in  which  the  purpose  of  self-destruc- 
tion was  put  into  practice.  In  both  the  impulse  was 
sudden,  nothing  up  to  the  moment  of  the  act  indicating 
premeditation. 

A  woman  of  fifty-two  years,  an  epileptic  since  her 
eighteenth  year,  who  suffered  from  both  grand  mal 
and  petit  mal  attacks,  generally  at  night,  and  not 
previously  depressed,  jumped  into  a  pond  with  suicidal 
intent.  On  being  rescued,  she  expressed  regret  for 
the  act,  and  four  years  later  had  shown  no  further 
inclination  that  way. 

A  young  man  of  twenty-two  years,  an  epileptic  for 
two  years  only,  whose  attacks  occurred  at  first  three 
months  apart,  but  later  in  series  of  from  six  to  eight 
every  three  or  four  weeks,  and  who  likewise  had  shown 
no  suicidal  intent  or  unusual  depression,  left  his  bed 
to  which  he  had  been  confined  a  few  days  through  a 
minor  illness,  crossed  the  hall  to  the  toilet  room,  and 
cut  his  throat,  death  occurring  some  hours  later. 

These  instances  are  cited  more  particularly  to  em- 
phasize the  unexpectedness  of  epileptics'  acts.  The 
line  of  continuity  of  conduct  with  them  in  any  radical 
way  is  seldom  changed  in  a  slow  and  orderly  manner, 
but  nearly  always  under  a  sudden  impulse.  In  some 
inexplicable  way  the  quick,  explosive  violence  of  the 
fit  itself  seems  to  find  parallels  in  action  in  most  of  the 
things  that  epileptics  do  out  of  the  usual  order. 


458         THE    PSYCHOLOGIC    ASPECTS    OF    EPILEPSY. 

We  are  speaking  now  of  a  characteristic  applicable 
to  the  great  majority.  It  does  not  include  a  few  whose 
powers  of  inhibition  seem  to  remain  intact  during  the 
inter-paroxysmal  period  and  even  in  rare  instances 
under  the  duress  of  the  lighter  and  less  frequent  forms 
of  the  disease. 

Almost  any  number  of  cases  might  be  cited  in  illus- 
tration of  the  manic-depressive  states  due  to  epilepsy. 
The  following  is  fairly  typical  of  the  majority  of  them : 

A.  E.  T.,  age  twenty  years  on  admission.  Had  been 
epileptic  since  fourteen.  Family  history  good.  Cause 
of  epilepsy,  masturbation.  The  patient  was  free  from 
any  stigmata  of  degeneration;  he  was  of  excellent 
disposition  and  good  education,  a  high-school  graduate. 
He  always  showed  perfect  self-control,  save  when 
under  the  influence  of  epileptic  attacks,  which  came  on 
at  first  from  twelve  to  fourteen  times  a  year,  being  alter- 
nately grand  mal  and  petit  mal.  Later  they  averaged 
from  eight  to  ten  a  month,  while  for  two  years  before 
the  attack  of  mental  disturbance  about  to  be  described, 
they  appeared  three  or  four  times  only  in  a  year. 

He  usually  had  a  psychic  aura,  and  would  become 
greatly  depressed  and  introspective ;  he  was  often  hallu- 
cinatory for  hours  after  the  attacks,  sight  and  hearing 
both  being  involved.  All  this  time,  during  the  inter- 
paroxysmal  periods,  he  remained  a  model  patient  in 
every  respect,  failing  to  show  any  evidence  of  the  effects 
of  his  disease. 

Fourteen  years  after  the  development  of  the  epi- 
lepsy, the  inter-paroxysmal  mental  condition  did  not 
show  the  least  sign  of  the  disease. 

In  the  meantime,  the  insane  periods  had  been  grow- 
ing more  intense  in  expression  and  occurred  closer 
together.  Isolated  seizures  left  him  automatic  for  a 
longer  time,  and  his  mental  vagaries  became  more 
marked  in  proportion  to  the  length  of  such  periods. 
Series,  of  attacks  were  attended  with  far  more  psycho- 
motor disturbances  than  that  common  to  isolated 
attacks.  While  the  latter  produced  simple  automatism 
and  mildly  expressed  insane  ideas,  the  former  turned 
him  into  a  typical  madman,  with  the  most  insane  and 


Plate  30. 


A  case  of  epileptic  dementia,  characterized  by  extreme  loss  of  psycho- 
motor activity  of  all  kinds — the  lowest  estate  an  epileptic  can  reach  save 
that  of  epileptic  idiocy 


TRANSITORY    PERIODIC    IRRITABILITY.  459 

insistent  ideas  shoutingly  expressed  with  exaggerated 
gestures,  and  forced  him  to  assault  any  who  came 
within  his  reach. 

He  had  such  an  attack  on  January  16,  1903,  which 
can  best  be  described,  in  part,  in  his  own  language, 
which,  however,  fails  to  give  any  idea  of  the  excessive 
degree  of  violence  he  manifested  at  the  time. 

"  I  had,"  he  states,  "a  severe  attack  on  the  night  of 
January  13th.  I  did  not  know  it  at  the  time,  but 
found  it  out  the  next  morning  from  my  sore  tongue, 
headache,  and  general  bad  feeling.  I  felt  bad  all  day, 
but  had  no  attack  the  next  night;  but  on  the  night 
of  the  15th  I  had  several  hard  fits,  and  several  more 
during  the  night  of  the  16th.  After  the  last  one,  I 
was  dressed  (I  do  not  recall  this,  but  was  told  so)  and 
taken  to  another  building.  I  remember  escaping  from 
this  building  through  an  attic  window  and  getting 
out  on  a  steep,  ice-covered,  slippery  roof.  It  was  my 
belief  that  those  in  charge  were  going  to  kill  and  cook 
me,  so  I  used  a  stick  to  keep  them  off.  I  also  pushed 
the  top  of  the  ladder  away  from  the  roof  to  keep  them 
from  coming  up  to  me.  I  heard  Mr.  A.  tell  the  cook 
to  help  kill  me.  I  saw  in  the  person  of  Mr.  A.  a  man  I 
knew  before  I  came  to  the  Colony.  I  also  heard  a 
man  say  he  was  another  man  I  knew  at  home,  and  I 
remember  I  did  not  believe  him  at  the  time.  I  have  no 
recollection  of  seeing  Mr.  McC.  or  Dr.  S.  while  I  was  on 
the  roof."  (Both  of  these  persons  talked  with  the 
patient  at  the  time.) 

Analysis  of  the  patient's  statements  shows  that  he 
presented  nearly  every  essential  feature  of  manic- 
depressive  insanity  due  to  epilepsy.  He  had  the 
delusions  of  persecution  characteristic  of  depression,  as 
shown  in  his  fear  of  being  killed  to  be  eaten;  he  had 
hallucinations  of  hearing,  as  shown  by  the  fact  that 
he  mistook  ordinary  conversation  for  commands  to  take 
part  in  his  execution;  he  had  hallucinations  of  sight, 
as  shown  by  his  belief  that  he  saw  a  person  in  the 
crowd  about  him  who  was  not  there;  all  these  being 
insistently  engrafted  upon  a  frenzied  bodily  activity, 
typically  characteristic  of  the  acutely  insane  epileptic. 


460         THE    PSYCHOLOGIC    ASPECTS    OF    EPILEPSY. 

His  excessive  psychomotor  violence  lasted  twelve 
hours,  gradually  fading  into  the  normal  state  seventy- 
two  hours  later. 

It  is  a  curious  fact  that  he  was  afterward  able  to 
recall  certain  incidents  only  that  transpired  while  his 
excitement  was  greatest.  Other  incidents  that  he 
appeared  cognizant  of  at  the  time,  as  shown  by  the 
conversation  he  carried  on  about  them,  he  was  wholly 
unable  to  recall. 

I  have  observed  that  the  incomplete  automatic 
state  (shown  to  be  incomplete  in  this  instance  by  the 
patient  doing  things  radically  different  from  those  he 
was  habituated  to  perform,  and  his  recollection  of  them 
afterward)  permits  the  patient  to  recall  some  things, 
but  to  show  no  knowledge  of  others  apparently  of  far 
greater  importance. 

The  question  of  automatism  in  such  a  state  as  this, 
however,  is  of  little  moment  from  a  medicolegal  stand- 
point as  compared  with  the  more  essential  fact  that 
the  patient  is  so  palpably  and  actively  insane. 

Very  rarely  we  may  meet  with  a  case  in  which  the 
prodromal  manifestations  of  the  fit  closely  simulate 
circular  insanity.  The  similarity  is  not  complete, 
however,  for  while  the  upward  growth  of  the  period 
of  psychomotor  exaltation  is  almost  identical,  the 
stage  of  decline  is  wholly  unlike. 

The  period  of  decline  in  folie  circulaire  is  gradual, 
fading  conspicuously  for  days  or  weeks  until  the  end 
of  the  cycle  is  reached  and  profound  melancholia  is 
established. 

In  the  epileptic  the  cycle  is  suddenly  cut  short  at 
the  end  of  the  upward  period  by  the  fit  which  abruptly 
dissipates-  all  morbid  psychomotor  phenomena  until 
the  beginning  of  the  next  cycle,  which  is  again  broken 
at  its  acme  in  the  manner  as  before. 

It  is  safe  to  say  (Fere,  Morel,  Doutrebente,  Soukey) 
that    we   rarely    meet   with    epileptics    who    are    well 


TRANSITORY    PERIODIC    IRRITABILITY.  461 

balanced  mentally  and  intellectually.  Their  character 
is  usually  mobile,  and  traits  of  depression  predominate. 
Habitually  gloomy,  irritable,  and  jealous,  they  may  be 
observed  to  pass  suddenly  to  sentiments  of  generosity, 
benevolence,  and  enthusiasm,  which  vanish  as  quickly 
as  the  paroxysms  to  which  they  are  subject. 

The  state  of  profound  depression  which  follows  the 
convulsive  discharges  presents  a  most  favorable  field 
for  the  development  of  feelings  of  sadness,  inferiority, 
and  impotence,  under  the  influence  of  which  suicidal 
impulses  sometimes  arise.  Their  frequent  hallucina- 
tions, the  terrifying  dreams  to  which  they  are  very 
liable,  render  such  persons  timorous,  suspicious,  and 
distrustful.  Their  tendencies  often  take  an  impulsive 
character,  but  rarely  they  may  manifest  tenacity  of 
purpose  or  true  energy.  The  mental  oscillations  which 
are  so  frequent  among  them  have  given  rise  to  the 
view  that  remittent  insanity  and  circular  insanity  are 
manifestations  of  masked  epilepsy. 

"The  lower  types  of  epileptics  exhibit  a  character- 
istic low  cunning  and  deceit ;  they  are  treacherous  in 
their  dealings  with  their  associates,  thievish  in  their 
propensities,  and  when  arraigned  upon  a  charge  of 
misconduct  will  meet  it  with  the  coolest  audacity, 
and  lie  to  the  bitter  end.  The  epileptic  shows  a  ten- 
dency, akin  to  that  of  the  hysteric,  toward  maligning. 
Both  will  falsely  accuse  of  violence  those  of  whom 
they  are  aggrieved;  will  treasure  up  a  tooth,  or  wil- 
fully pull  out  their  own  hair  by  the  handful  and  present 
it  to  countenance  their  charge,  and  will  cunningly 
call  to  their  defense  certain  delusional  notions  to  which 
they  may  be  prone  during  the  period  of  their  seizures, 
if  they  can  benefit  their  position  thereby.  This  ten- 
dency should  be  carefully  borne  in  mind.  All  the 
apparent  delusional  statements  of  an  epileptic  are  not 
to  be  received,  except  with  caution,  as  their  sole  object 
may  be  to  obtain  some  indulgence  or  request,   and 


462         THE    PSYCHOLOGIC    ASPECTS    OF    EPILEPSY. 

especially  is  it  so  with  the  hypochondriacal  subject" 
(Bevan  Lewis). 

Associated  with  this  moral  decadence  the  epileptic 
is  also  essentially  impulsive,  a  feature  demanding  the 
utmost  tact  in  his  care.  His  conduct  when  aroused  is 
peculiarly  brutal  and  ferocious,  and  often  characterized, 
like  his  actions  during  periods  of  epileptic  automatism, 
by  wholly  disproportionate  and  excessive  violence. 

The  statements  of  Fere,  Marie,  Doutrebente,  Morel, 
Bevan  Lewis,  and  others,  relative  to  the  general  mental 
equipment,  and  especially  the  abundance  of  moral 
decadence  in  the  epileptic  as  the  result  of  his  disease, 
are  not  overdrawn  in  a  very  large  number  of  cases. 
The  picture  is  not  a  happy  one.  Nevertheless,  too 
often  it  is  true.  Many  of  the  better  epileptics,  such 
as  usually  visit  the  consultation  room  of  the  physician, 
do  not  show  such  characteristics. 

In  Krafft-Ebing's  Psychopathia  Sexualis  (pp.  364  to 
374),  numerous  illustrations  are  found  of  the  debased 
moral  practices  and  tendencies  of  many  epileptics  as 
exhibited  when  apparently  under  the  influence  of  the 
disease.  Similar  cases,  little  less  shocking,  have  come 
under  my  own  observation.  Some  such  will  be  found 
in  every  aggregation  of  epileptics  of  any  considerable 
size. 

In  any  large  aggregation  of  epileptics  in  which  there 
are  none  actively  insane,  scores  may  be  found  whose 
conduct  in  every  respect  is  exemplary. 

Mental  capacity  in  epilepsy  is  impaired  to  some 
extent  in  the  great  majority  of  cases.  Any  disease 
that  so  radically  affects  the  brain  must  produce  this 
result.  There  is  no  method  of  accurately  estimating 
the  frequency  and  degree  of  mental  reduction  due  to 
epilepsy.  While  certain  cases  naturally  fall  in  quite 
constant  resultant  groups  in  this  respect,  each  is 
finally  a  problem  in  its  own  right. 

But  there  is  this  about  every  case :  the  most  impor- 


MENTAL    CAPACITY    IN    EPILEPSY.  463 

tant  legal  question  bearing  on  mental  reduction  con- 
cerns chiefly  the  duration  of  such  reduction.  We  can 
summarize  the  points  of  this  in  this  manner : 

1 .  The  reduction — amounting  in  some  cases  to  abso- 
lute destruction — may  be  measured  in  point  of  time 
by  a  few  seconds  only,  such  reduction  periods  being 
not  infrequently  months  apart.  The  inter-paroxysmal 
condition  of  such  patients  may  be  perfectly  normal  so 
far  as  we  can  determine. 

2.  The  reduction  may  be  frequent  in  point  of  occur- 
rence, varying  from  several  hundred  seizures  in  twenty- 
four  hours  to  one  or  two  in  a  day,  or  as  many  in  a 
month.  The  inter-paroxysmal  condition  in  such  cases 
is  generally  one  of  permanent  irresponsibility ;  in  others 
in  which  the  seizures  are  less  frequent,  there  may  be 
rational  intervals. 

3.  The  reduction  may  be  permanent,  covering  both 
the  paroxysmal  and  the  inter-paroxysmal  period,  so 
that  the  individual  is  continuously  irresponsible.  The 
degrees  of  mental  destruction  under  this  head  include 
feeble-mindedness,  imbecility,  idiocy,  dementia,  and 
the  manic-depressive  states  previously  described. 

It  is  difficult  to  say  what  proportion  of  epileptics 
suffer  in  the  lighter  degree  only,  but  it  is  safe  to 
estimate  the  number  at  not  to  exceed  from  8  per  cent, 
to  10  per  cent.  These  may  be  called  sane,  both 
within  the  legal  and  scientific  meaning,  except  at  the 
brief  moment  of  attack. 

The  number  coming  under  the  second  heading 
includes  fully  50  per  cent,  of  them  all;  those  under  the 
third,  the  remaining  40  per  cent.,  which  we  may  again 
divide  into  two  parts,  the  idiots  and  imbeciles  repre- 
senting from  20  per  cent,  to  25  per  cent.,  and  the 
continuously  insane  (such  as  are  recognized  by  law 
and  medicine  alike)  from  15  per  cent,  to  20  per  cent. 

The  general  practitioner  rarely  comes  in  contact  for 
any  length  of  time  with  cases  under  the  third  categorv. 


464  GENIUS    AND    EPILEPSY. 

He  is  mostly  familiar  with  those  whose  disease  is  com- 
paratively recent,  and  of  a  type  least  destructive  of 
mentality,  so  that  he  is  called  upon,  as  a  rule,  to  treat 
only  the  better  classes,  and  then  he  generally  sees 
these  when  they  are  at  their  best,  rarely  being  able  to 
witness  the  convulsions  and  their  effects  on  the  mind. 

Much  has  been  written  on  the  relationship  between 
genius  and  epilepsy.  I  cannot  feel  that  any  disease, 
in  which  the  tendency  to  loss  of  mental  power  is  so 
great  as  in  epilepsy,  is  capable  of  conferring  unusual 
intellectual  capacity.  I  agree  with  Sir  Lauder  Brun- 
ton  when  he  says,*  "  It  is  quite  true  that  some  of  the 
most  remarkable  men  in  the  world's  history  have 
been  epileptics,  but  I  do  not  think  that  Julius  Csesar, 
Napoleon,  or  Mohammed  were  great  because  they  were 
epileptics.  As  a  rule,  epilepsy  tends  to  destroy  mental 
power  rather  than  to  increase  it,  and  the  curious 
lethargy  which  Napoleon  exhibited  at  the  Battle  of 
Leipzig,  and  which  there  led  to  his  defeat  and  conse- 
quent ruin,  is  probably  rather  to  be  ascribed  to  his 
epileptic  tendency  than  to  the  indigestible  bun  which 
is  said  to  have  led  to  the  disaster.  Julius  Cassar  and 
Napoleon  were  great  men,  not  because  of  their  epilepsy, 
but  in  spite  of  it ;  and  the  visions  of  Mohammed  alone 
would  not  have  given  him  his  extraordinary  power 
over  his  countrymen  and  over  the  then  known  world, 
had  it  not  been  that  they  were  backed  up  by  extra- 
ordinary mental  power  and  energy  in  the  intervals 
between  his  fits." 

Lombroso  t  devotes  a  chapter  to  The  Epileptoid 
Nature  of  Genius.  He  says:  "  It  is  sufficient  .  .  .  . 
to  recall  to  the  reader  the  numerous  men  of  genius 
of  the  first  order  who  have  been  seized  by  motory 
epilepsy,  or  by  that  kind  of  irritability  which  is  well 
known   to   supply   its   place.     Among   these   we   find 

*  "Journal  of  Mental  Science,"  xlviii,  No.  201,  April,  1902. 
t  "The  Man  of  Genius." 


TRANSITORY    PERIODIC    IRRITABILITY.  465 

Napoleon,  Moliere,  Julius  Caesar,  Petrarch,  Peter  the 
Great,  Mohammed,  Handel,  Swift,  Richelieu,  Charles 
V.,  Flaubert,  Dostoieffsky,  and  St.  Paul." 

Lombroso  admits  that  convulsions  made  their  ap- 
pearance rarely  in  the  course  of  the  lives  of  these  men, 
and  suggests  that  they  were  replaced  by  psychic 
equivalents,  which,  according  to  his  views,  "are  more 
frequent  and  intense  when  motor  convulsions  are 
lacking"- — a  proposition  I  am  unable  to  accept. 

Because  an  epileptic  fails  to  have  frequent  motor  or 
psychomotor  convulsions  is  no  reason  why  he  should 
have  frequent  psychic  attacks. 

Above  all,  in  Lombroso's  opinion,  is  the  relationship 
between  genius  and  epilepsy  to  be  proved  "through 
the  analogy  of  the  epileptic  seizure  with  the  moment 
of  inspiration,"  and  it  is  further  demonstrated  by  the 
even  more  cogent  proof — the  confession  of  eminent 
men  of  genius,  such  as  Goncourt,  Buffon,  Mohammed, 
and  Dostoieffsky."  The  finest  illustration  of  this  to 
be  found  in  the  literature,  perhaps,  is  by  Dostoieffsky 
in  "The  Idiot,"  Vol.  I,  p.  296. 

"I  remember,"  says  the  author  (evidently  referring 
to  himself),  "among  other  things  a  phenomena  which 
used  to  precede  his  epileptic  attacks  when  they  came 
in  the  waking  state.  In  the  midst  of  the  dejection, 
the  mental  marasmus,  the  anxiety,  which  the  madman 
experienced,  there  were  moments  in  which  all  of  a 
sudden  the  brain  became  inflamed,  and  all  his  vital 
forces  suddenly  rose  to  a  prodigious  degree  of  intensity. 
The  sensation  of  life,  of  conscious  existence,  was  multi- 
plied tenfold  in  these  swiftly  passing  moments.  A 
strange  light  illumined  his  heart  and  mind.  All  agita- 
tion was  calmed,  all  doubt  and  perplexity  resolved 
itself  into  a  superior  harmony,  a  serene  and  tranquil 
gaiety,  which  yet  was  completely  rational.  But  these 
radiant  moments  were  only  a  prelude  to  the  last- 
3° 


466         THE    PSYCHOLOGIC    ASPECTS    OF    EPILEPSY. 

instant — that  immediately  succeeding  the  attack. 
That  instant,  in  truth,  was  ineffable." 

Later  on  when  the  attack  was  over,  the  author's 
reflections  ran  thus :  "  Those  fleeting  moments  in  which 
our  highest  consciousness  of  ourselves — and  therefore 
our  highest  life— is  manifested,  are  due  to  disease,  to 
the  suspension  of  normal  conditions;  and,  if  so,  it  is 
not  a  higher  life,  but,  on  the  contrary,  one  of  lower 
order." 

Strangely  enough,  he  then  goes  on  to  say:  "What 
matter,  after  all,  though  it  be  a  disease — an  abnormal 
tension — if  the  result  (as  I  will  recover  health,  remem- 
ber, and  analyze  it)  includes  the  highest  degree  of 
harmony  and  beauty. ' ' 

Lines  from  the  correspondence  of  Flaubert  contain 
the  following  expressions  significant  of  the  acute 
epileptic  state.  "  I  who  have  heard  through  closed 
doors  people  talking  in  low  tones  thirty  paces  away 
(hallucinations  of  sound),  across  whose  abdomen  one 
may  see  the  viscera  throbbing,  and  who  have  some- 
times felt  in  the  space  of  a  minute  a  million  thoughts, 
images,  and  combinations  of  all  kinds  throwing  them- 
selves into  my  brain  at  once,  as  it  were  a  lighted  squib 
of  fireworks." 

The  confessions  of  Dostoieffsky  and  Flaubert  are 
similar  to  feelings  described  to  me  by  epileptics  of 
superior  intellectual  endowment.  Two  in  particular 
detailed  the  sensations  of  intellectual  aura  they  ex- 
perienced, which  would  readily  pass  for  these  confes- 
sions. They  had  such  aura  rarely,  and  declared  it  to 
be  "  the  most  overwhelming  ecstatic  state  it  is  possible 
for  the  human  mind  to  conceive  of."  Both  were 
teachers  of  noted  ability  and  both  developed  epilepsy 
through  excessive  alcoholic  indulgence — not  drinking 
enough  at  one  time  to  produce  drunkenness,  but 
drinking  systematically  for  years  to  fortify  a  nervous 
system  exhausted  through  overwork. 


TRANSITORY    PERIODIC    IRRITABILITY.  467 

No  less  interesting  than  the  foregoing  are  Sweden- 
borg's  insane  manifestations  due  to  epilepsy.* 

Always  eccentric  to  a  marked  degree,  it  was  not 
until  his  fifty-fifth  year  that  his  particular  malady 
became  conspicuous. 

Authenticated  instances  in  detail  are  cited  by 
Maudsley,  in  which  Swedenborg  passed  through  all  the 
phases  of  the  epileptic  convulsion,  even  to  frothing 
at  the  mouth.  A  record  in  his  diary  is  this:  "There 
happened  to  me  something  very  curious.  I  came  into 
violent  shudderings,  as  when  Christ  showed  me  His 
Divine  Mercy.  The  one  fit  followed  the  other  ten  or 
fifteen  times."     Apparently  this  meant  serial  epilepsy. 

"In  1874,  when  he  was  fifty-five  years  of  age,"  says 
Maudsley,  "Swedenborg  suddenly  abandoned  his 
former  pursuits  and  interests.  He  claimed  to  have 
been  admitted  into  the  spiritual  world,  and  that  he 
possessed  the  power  of  talking  with  angels.  Coinci- 
dently  with  this  great  change  and  new  missions,  he 
was  entering  into  what  an  unprejudiced  person  must 
affirm  to  be  the  product  of  madness;  this  condition 
finally  developing  in  unmistakable  form." 

"Is  it  not  reasonable,"  asks  Maudsley,  "to  infer 
that  those  new  and  strange  pictures  were  the  outcome 
of  his  madness?  His  disciples  say  not,  but  those 
familiar  with  the  product  of  diseased  epileptic  fancies 
see  nothing  but  epileptic  phenomena  in  them." 

Because  of  the  frequency  and  extent  to  which  epi- 
lepsy impairs  the  emotional  balance,  for  the  same  reason 
apparently  it  stimulates  the  creation  of  delusions, 
hallucinations,  and  illusions  that  partake  of  a  religious 
order,  or  are  wholly  religious  in  their  expressions.  So 
long  as  such  phenomena  remain  free  from  interpreta- 

*  We  only  touch  upon  the  vagaries  of  this  unique  character  in  this  con- 
nection, and  suggest  to  those  who  wish  to  pursue  the  subject  further,  the 
reading  of  Maudsley's  "Body  and  Mind,"  and  William  White's  "Emanuel 
Swedenborg:  His  Life  and  Writings." 


468         THE    PSYCHOLOGIC    ASPECTS    OF    EPILEPSY. 

tion  by  the  patient  as  constituting  divine  commands, 
the  individual  is  less  likely  to  do  violence  than  when 
he  feels  impelled  to  earn'  out  such  commands.  It  is 
never  wise  to  assume  that  epileptics  of  morbid  religious 
tendencies  are  safe  to  be  at  large.  Divine  commands 
appear  to  them  as  sudden  inspirations  and  generally 
lead  to  acts  of  great  violence.  Without  exception 
such  persons  require  the  restraint  of  hospitals  for  the 
insane. 

L.  B.,  a  young  adult  epileptic,  proclaimed  these 
sentiments  for  months:  "  God  has  told  me  that  in  my 
next  life  I  would  be  born  of  C.  H.  S.  and  marry  my 
last  sweetheart,  and  be  a  millionaire,  and  that  I  would 
be  a  strong,  hopeful,  good,  powerful  Christian  mil- 
lionaire. I  feel  God's  voice  in  my  left  ear  at  night. 
I  feel  the  Lord  in  my  chest.  I  see  stars  in  my  eyes 
during  the  day,  which  are  the  Holy  Spirit.  I  have 
seen  Christ  crucified.  I  am  cured  of  my  fits;  I  have 
worked  them  off  by  asking  the  good  Lord  to  forgive 
my  sins.  God  told  me  I  would  never  have  any  more 
fits.  God  told  me  to  bite  off  a  patient's  ear.  If  God 
told  me  to  do  wrong,  it  feels  as  if  I  would  do  it.  God 
told  me  the  world  was  coming  to  an  end  very  soon. 
The  Holy  Spirit  has  been  working  on  me  twenty-two 
weeks."* 

It  has  often  been  observed  that  the  nature  of  the 
delusion  bears  some  relationship  to  the  character  of  the 
mind  from  which  it  springs.  The  form  of  the  insane 
person's  vocation  is  therefore  likely  to  be  reflected  in 
the  genesis  of  his  delusions.  It  seems  as  reasonable  to 
picture  the  expression  of  morbid,  exalted,  and  ecstatic 
states  encompassing  a  wealth  of  perverted  intellectu- 
ality as  coming  from  minds  of  great  natural  endow- 
ment, such  as  Mohammed's,  Swedenborg's,  and  others, 

*  Shortly  before  his  commitment  to  a  hospital  for  the  insane,  he  en- 
deavored to  obey  a  "divine  command"  by  almost  biting  off  a  fellow-patient's 
ear. 


TRANSITORY    PERIODIC    IRRITABILITY.  469 

as  to  picture  more  commonplace  delusions  as  springing 
from  minds  of  inferior  capacity.  Had  Swedenborg  or 
Mohammed  been  actively  epileptic  in  their  youth, 
probably  neither  would  have  stamped  his  individuality 
upon  history  as  he  did. 

We  are  told  that  the  picture  given  the  world  by 
Taine  is  the  completest  view  of  Napoleon  ever  given 
by  any  historian.  "To  any  one  acquainted  (we  quote 
again  from  Maudsley)  with  the  psychologic  constitu- 
tion of  the  epileptic  it  becomes  clear  that  Taine  has 
given  us  the  subtlest  and  most  precise  pathologic 
diagnosis  of  a  case  of  psychic  epilepsy  with  its  giant 
megalomaniacal  illusions,  its  impulses,  and  complete 
absence  of  moral  sense." 

"I  see  no  reason,"  says  Professor  William  M.  Sloan, 
author  of  a  most  admirable  and  complete  "  Life  of 
Napoleon,"  "to  question  the  fact  that  Napoleon  I 
was  an  epileptic.  There  were,  I  think,  two  instances 
when  he  had  short  seizures  which  did  not  amount  to 
fits,  but  were  regarded  by  contemporaries  as  symp- 
toms of  epilepsy." 

It  seems  evident  that  such  attacks  were  either  petit 
mat  or  psychic,  similar  to  those  experienced  by  Julius 
Caesar.  In  Appian's  "Roman  History"  we  find  this 
reference  to  Caesar:  "At  length,  whether  he  lost  all 
hope,  or  else  for  the  better  preservation  of  his  health, 
never  more  afflicted  with  the  falling  sickness  and  sud- 
den convulsions  than  when  he  lay  idle,  he  resolved 
upon  a  far  distant  expedition  against  the  Gatae  and  the 
Parthians." 

In  Seutonius's  "Lives  of  the  Caesars"  we  also  find 
the  following  concerning  Julius  Caesar.  "He  is  said 
to  have  been  tall,  of  a  fair  complexion,  round-limbed, 
rather  full-faced,  with  black  eyes,  and  lively;  very 
healthful,  except  toward  the  end  of  his  life  he  would 
suddenly  fall  into  fainting  fits,  and  be  frightened  in 


470         THE    PSYCHOLOGIC    ASPECTS    OF    EPILEPSY. 

his  sleep.     He  was  twice  seized  with  the  falling  sick- 
ness in  time  of  battle." 

We  might  continue  to  pursue  the  study  of  men  of 
genius  written  in  history  as  epileptics  in  a  far  more 
elaborate  way,  without  learning  anything  more  convinc- 
ing than  the  facts  apparent  in  the  cases  cited,  namely, 
that  none  of  them  had  essential  epilepsy  in  early  life,  so 
far  as  history  goes  to  show ;  that  they  all  developed  it 
late  in  life  in  comparatively  mild  forms — in  forms  not 
incompatible  with  the  highest  intellectual  endowment ; 
which  latter,  however,  must  be  developed  in  full  before 
the  establishment  of  the  disease,  and  which  the  true  dis- 
ease tends  in  every  case  to  impair  or  destroy. 


CHAPTER  XVII. 
THE  MEDICOLEGAL  ASPECTS  OF  EPILEPSY. 

Pre-paroxvsmal  Forms  of  Mental  Disturbance.  Religious  Emotionalism. 
Transitory  Epileptic  Irritability.  Paroxysmal  Epileptic  Insanity.  Post- 
epileptic Automatism.  Characteristic  Conditions  under  which' Epileptics 
Commit  Homicides.      Cases  in  Illustration.      Epilepsy  and  Life  Insurance. 

The  medicolegal  problems  in  epilepsy,  like  those  of 
insanity,  relate  to  the  mental  condition  at  the  time 
of  the  commission  of  a  crime  or  act,  or  voicing  of  an 
expression,  for  which  the  accused  person  cannot 
rightfully  be  held  responsible,  and  to  charges  brought 
by  epileptics  against  others  for  injuries  sustained 
during  an  attack.  It  may  also  be  a  question  at  law 
as  to  an  injury  resulting  from  actionable  negligence 
in  a  case  of  epilepsy. 

While  the  insane  manifestations  in  epileptics  often 
partake  of  the  same  general  characteristics,  such  as 
explosiveness,  great  violence,  and  brutality,  there  is 
no  rule  by  which  all  cases  can  be  studied  alike. 

We  have  previously  noted  that  epileptic  seizures 
of  certain  types  may  occur  for  many  years  without 
appreciably  impairing  the  mental  faculties,  while 
others  destroy  the  mind  in  much  less  time. 

We  can  best  study  mental  reductions  incident  to 
epilepsy  and  its  correlated  question  of  responsibility 
by  considering  them  in  their  relationship  to  the  seizure 
periods,  i.  e.,  whether  they  precede,  accompany,  are 
substituted  for,  or  follow  the  attacks,  or  whether  the 
insane  state  exists  continuously  irrespective  of  the 
epileptic  "discharges." 

Pre-paroxysmal  Forms  of  Mental  Disturbance. — The 
psychic  aura  that  sometimes  appears  days  before  the 

471 


472        THE    MEDICOLEGAL    ASPECTS    OF    EPILEPSY. 

seizure  may  be  often  regarded  as  a  species  of  insanity. 
Persons  in  this  state,  as  a  rule,  know  the  nature  and 
quality  of  the  wrongful  acts  they  commit,  but  they 
suffer  so  complete  a  paralysis  of  the  powers  of  inhibi- 
tion that  they  are  incompetent  to  restrain  themselves. 
Others  have  no  knowledge  of  what  is  going  on  about 
them  when  in  the  deeper  reduction  of  a  psychic  aura 
just  before  the  fit. 

An  intelligent  woman  of  forty-three  years,  who  was 
under  my  care  for  some  years,  had  an  unusually 
pleasant  disposition,  except  about  the  times  of  her 
seizure  periods.  For  days  before  these,  she  would  be 
mildly  excited,  loquacious,  alternately  crying  and 
laughing,  complaining  one  moment  of  fancied  evil 
remarks  made  about  her,  and  the  next  vehemently 
asserting  that  the  fault  all  lay  in  herself.  She  was 
nervous,  restless,  irritable,  and  sleepless;  she  com- 
plained of  strange  cephalic  sensations;  her  face  was 
flushed,  her  eyes  unnaturally  bright,  and  her  gait 
unsteady  to  the  point  of  stumbling.  She  described 
her  feelings  while  in  this  state  as  follows : 

"  This  is  now  the  2 2d  of  February,  1902.  I  had  four 
very  severe  attacks  on  the  31st  of  last  January.  I  felt 
the  attacks  coming  for  a  long  time  before  they  came. 
I  was  exceedingly  nervous  and  irritable;  I  scolded 
about  everything  and  was  unable  to  hold  things  in  a 
proper  manner.  When  I  picked  up  my  brush  and 
comb,  I  would  drop  them,  and  when  I  walked  I 
stepped  crooked — one  foot  would  keep  making  mis- 
takes and  I  didn't  know  which  foot  it  was.  They  said 
it  was  the  left.  I  could  not  sleep  at  all.  I  lay  think- 
ing of  things  that  had  happened  and  that  were  not 
pleasant;  I  tried  to  put  them  out  of  my  mind  by 
thinking  of  what  I  had  read.  I  have  a  strong  will  and 
feel  that  I  can  control  my  thoughts  at  most  times; 
but  for  days  before  the  attacks  come  on,  I  am  unable  to 
do  so.  They  go  off  about  everything,  and  I  try  to 
make  them  come  back,  but  they  won't.  They  get 
worse  every  day  and  night,  and  finally  they  get  all 
jumbled  up  together,  and  I  don't  know  anything. 
Then  the  attacks  come  on,  and  after  that  I  am  all 
right — everything  clears  up  and  I  see  things  as  they 


PARADOXICAL    RELIGIOUS    EMOTIONALISM.  473 

really  are.     I  lose  all  my  nervousness  and  can  act 
rationally. ' ' 

During  the  greater  part  of  this  morbid  state,  the 
patient  was  not  only  conscious  of  what  she  was  doing, 
but  knew  full  well  the  import  of  every  act.  Several 
times  while  in  this  state  she  made  groundless  com- 
plaints against  the  nurse,  which  she  retracted  either 
immediately  or  as  soon  as  the  fit  had  passed,  declaring 
they  were  unjust.  The  main  point  is  that  she  was 
powerless  to  inhibit  such  conduct.  The  line  between 
this  state  and  insanity  is  delicate  in  the  extreme. 
Scientifically  it  is  insanity;  legally,  it  might  not  be 
so  regarded. 

The  principle  of  freedom  from  responsibility  through 
defective  inhibition  was  sustained  by  Judge  H.  M. 
Somerville,  of  the  Supreme  Court  of  Alabama,  in  1887. 
He  rendered  a  decision  that  repudiated  the  test  of 
insanity  laid  down  in  the  celebrated  McNaughton  case 
in  England.  The  test  in  this  case  was  the  ability  to 
distinguish  between  the  right  and  wrong  of  the  act  in 
question.  Judge  Somerville  held  that  the  true  test  of 
responsibility  in  cases  of  insanity  is  the  power  to 
refrain  from  doing  the  act;  in  other  words,  the  ques- 
tion to  be  decided  was,  whether  the  alleged  evil-doer 
acted  under  duress  of  a  disease  which  had  impaired  or 
destroyed  his  powers  of  inhibition. 

Paradoxical  religious  emotionalism  is  apt  to  be  mani- 
fested by  epileptics  just  before  the  seizure  periods 
and  should  always  be  regarded  as  a  danger  signal. 
Clouston  *  mentions  a  lad  in  whom  it  was  a  sure  pre- 
lude to  a  fit  or  a  series  of  fits.  Before  these  periods, 
the  patient  read  his  Bible  continually,  and  when 
spoken  to  answered  fiercely,  "Don't  trouble  me;  I  am 
a  good  man;  I'm  a  servant  of  God."  The  day  after 
he  would  walk  up  and  down  and  strike  any  one  who 
came  near  him.     If  any  one  spoke  to  him,  he  replied 

*    "Mental  Diseases,"  1884,  p.  288. 


474         THE    MEDICOLEGAL    ASPECTS    OF    EPILEPSY. 

maniacally,  "  You  are  a  d d  liar.     Don't  insult  me." 

In  a  few  hours  he  would  have  one  or  more  fits,  remain 
stupid  for  awhile,  then  be  as  well  as  ever. 

A  man  of  forty-three  years,  under  my  care,  whose 
epilepsy  had  followed  scarlatinal  nephritis  at  the  age 
of  seven  years,  and  who  was  subject  to  long  remissions 
in  his  disease,  had  serial  attacks  from  three  to  four 
weeks  apart.  The  first  indication  noted  of  his  ap- 
proaching fits  was  his  fault-finding  at  the  table.  He 
suddenly  objected  to  his  neighbor,  calling  him  a  vile 
name.  At  the  next  meal  he  refused  to  sit  beside  him 
and  at  the  next  meal  he  failed  to  appear  at  all.  He 
was  found  in  his  room  shortly  after,  moody,  sullen,  and 
irritable,  reading  his  Bible.  He  kept  this  up  all  night 
and  the  better  part  of  the  following  day,  when  he 
suddenly  lay  his  Bible  aside  and  began  to  loudly 
revile  everyone  within  hearing,  in  the  most  profane 
and  violent  language.  On  his  finally  attempting  to 
assault  his  nurse  and  physician,  he  was  placed  in 
restraint.  A  few  hours  later,  he  had  three  severe 
attacks  in  rapid  succession,  six  hours  after  which  he 
was  composed  and  agreeable  to  all  about  him.  His 
malady  followed  this  course  for  many  years. 

Comparatively  few  epileptics  have  such  a  distinctive 
psychic  aura.  In  1325  cases  under  my  observation, 
33  men  and  19  women  manifested  it  in  some  form — 
most  of  them  to  a  less  extent.  Its  relative  infrequency 
makes  overt  acts  performed  under  its  influence  rare. 

Such  epileptics  should  not  be  regarded  as  mentally 
sound  at  any  time.  They  often  experience  subcon- 
scious automatic  states  in  which  they  display  no 
violence,  in  which  they  are  wholly  without  conscious 
volition.  • 

Transitory  Epileptic  Irritability. — I  have  previously 
spoken  of  the  effects  of  epilepsy  on  the  disposition. 
These  are  especially  noticeable  before  the  fit.  The 
patient    becomes    querulous,    exacting,    fault-finding; 


TRANSITORY    EPILEPTIC    IRRITABILITY.  475 

nothing  suits  him;  he  fancies  his  friends  untrue,  and 
charges  his  family  with  deserting  him.  He  impugns 
the  motive  of  all  about  him ;  is  incapable  of  continuous 
application;  unable  to  sleep  well,  and  has  terrifying 
dreams.  Morbid  ideas  finally  assume  complete  mas- 
tery over  him.  As  a  rule,  these  ill-humor  periods  end 
in  a  convulsion.  They  may  come  and  go  independ- 
ently of  typical  seizures. 

There  should  always  be  a  doubt  as  to  the  responsi- 
bility of  epileptics  who  commit  wrongful  acts  while  in 
this  state.  In  some  it  is  impossible  to  say  that  such 
a  state  is  not  the  result  of  a  preceding  unrecognized 
convulsion. 

Epileptics  not  infrequently  assault  those  about  them 
when  in  this  humor.  In  any  large  epileptic  com- 
munity, such  events  are  of  daily,  occurrence. 

Innumerable  instances  have  come  under  my  ob- 
servation in  which  epileptics  have  charged  their  at- 
tendants with  brutal  conduct,  and  in  which  investiga- 
tion showed  the  charges  to  be  either  malicious  at- 
tempts to  injure  others  or  the  result  of  the  perverted 
sensations  so  common  in  epilepsy.  I  have  found  the 
latter  more  often  the  case  than  the  former.  This  is 
readily  understood. 

When  a  fit  is  about  to  appear,  the  patient  is  seized 
with  the  most  terrifying  apprehensions.  He  is  in  an 
agony  of  fear.  All  his  senses  are  stirred  to  a  profound 
degree  and  he  is  imperfectly  conscious  of  what  is  hap- 
pening about  him.  An  attendant  grasps  him  to 
assist  him.  When  the  fit  is  over,  feeling  bruised  and 
sore  as  the  inevitable  result  of  the  attack,  he  accuses 
the  attendant  with  having  assaulted  him.  I  have  also 
known  numerous  instances  in  which  the  patient 
declared  that  harsh  language  had  been  used  toward 
him,  his  conception  being  due  to  hallucinations  of 
hearing — not  a  word  having  been  spoken  by  those 
about  him.     Others,  on  suddenly  experiencing  a  dis- 


476        THE    MEDICOLEGAL    ASPECTS    OF    EPILEPSY. 

tressing  ringing  in  the  ears  just  before  they  become 
•unconscious,  and  being  injured  about  the  head  by 
falling  during  the  fit,  afterward  declare  that  some  one 
struck  them  on  the  head. 

The  most  common  complaint  is  based  on  the  feeling 
of  suffocation  the  patient  experiences  just  as  he  is 
passing  into  oblivion,  and  which  he  very  frequently 
says  is  due  to  some  one  kneeling  on  his  chest  purposely 
to  injure  him.  While  all  epileptics  do  not  have  these 
periods  of  ill-humor  and  hallucinations,  the  majority 
do.  To  prevent  injustice  to  innocent  persons,  epileptic 
testimony  needs  to  be  received  with  great  caution. 

Paroxysmal  Epileptic  Insanity. — Unquestionably  the 
gravest  criminal  result  of  epilepsy  is  the  commis- 
sion of  assaults  and  inhuman  crimes  during  the  fit 
itself  or  during  the  automatic  state  that  immediately 
follows  it. 

From  the  earliest  times  its  mental  accompaniments 
have  increased  the  mystery  and  terror  of  epilepsy. 
When  added  to  the  contortions  and  unconsciousness 
of  that  disease  during  a  fit,  there  are  afterward  devel- 
oped strange  hallucinations,  terrible  acts  of  impulsive 
violence,  and  striking  religious  delusions,  we  cannot 
wonder  that  a  supernatural  cause  was  almost  univer- 
sally believed  in  of  old. 

"  I  have  seen  epileptic  insanity  take  the  form  of  a 
more  acute  maniacal  condition  than  almost  any  other 
insanity,  with  the  exception  of  mania  from  alcohol. 
There  is  no  other  form  of  insanity  outside  of  asylums 
so  frequently  the  cause  of  murders"  (Clouston). 

"The  excitement  in  epileptic  mania  is  most  acute. 
No  maniacs  show  such  blind,  incalculating  violence  and 
frequent' fury  as  the  epileptic.  He  is  one  of  the  most 
dangerous  subjects  we  have  to  deal  with  in  our  asylums. 
The  aspect  of  the  patient  fully  accords  with  the  impul- 
sive conduct.  He  is  usually  pale  and  ghastly,  the 
eyes  staring  vacantly,  and  the  face  expressionless  or 


PAROXYSMAL    EPILEPTIC    INSANITY.  477 

betraying  wild  and  passionate  emotion"  (Bevan 
Lewis). 

"The  nervous  excitability  may  increase  as  the  time 
for  the  attack  approaches,  and  before  its  occurrence  a 
maniacal  outbreak  of  great  violence  may  take  place, 
during  which  the  most  brutal  and  wantonly  cruel  acts 
may  be  committed.  Such  acts  may  be  against  relatives 
or  best  friends,  but  sometimes  persons  with  whom  the 
epileptic  has  not  been  on  the  best  of  terms  suffer,  thus 
giving  the  deeds  of  violence  a  superficial  appearance  of 
having  been  premeditated"  (Peterson  and  Haines). 

The  following  cases  from  the  literature  and  from  my 
own  experience  show  in  some  detail  the  nature  of  such 
acts  and  the  circumstances  under  which  they  are 
usually  committed: 

Case  I. — P.  P.,  a  young  man  of  twenty-four,  a  native 
of  Greece,  was  indicted  and  tried  for  murder  in  the 
first  degree  for  shooting  to  death  his  partner  in  busi- 
ness. Competent  testimony  was  adduced  to  show  that 
the  defendant  and  the  man  he  killed  had  been  the 
best  of  friends  for  years ;  that  there  was  absolutely  no 
motive  for  the  crime ;  and  that  the  defendant  not  only 
came  from  an  epileptic  family,  but  was  himself  a  victim 
of  the  disease. 

On  its  face,  the  murder  bore  every  evidence  of  a 
cold-blooded  crime.  In  the  presence  of  witnesses  the 
two  men  quarreled  while  trying  to  adjust  a  small 
account.  Angry  words  passed  between  them,  and 
ugly  insinuations,  derogatory  to  the  fiancee  of  the  de- 
fendant, were  made,  when  he  suddenly  drew  a  revolver 
and  fired  five  shots  pointblank  at  his  partner  as  fast 
as  a  self-acting  revolver  would  work,  three  of  them 
taking  effect  and  causing  death. 

Witnesses  testified  that  the  defendant  then  threw 
his  revolver  on  the  floor  and  made  no  effort  to  escape. 
It  was  also  testified  that  he  was  heard  shortly  after- 
ward to  say,  "  It's  too  bad;  it's  too  bad!"  The  shoot- 
ing occurred  about  a  quarter  past  twelve  in  the  after- 
noon, and  the  defendant  was  at  once  lodged  in  jail. 
Other  witnesses  testified  that  after  the  defendant  was 


478        THE    MEDICOLEGAL    ASPECTS    OF    EPILEPSY. 

in  jail  and  when  asked  what  he  was  doing  there,  replied, 
"I  shot  George." 

In  his  own  testimony  on  the  stand  the  defendant 
declared  that  his  mind  was  a  blank  from  the  time  of 
the  quarrel  in  the  store  until  he  came  to  his  senses 
in  the  jail  about  two  hours  and  a  quarter  later,  and 
that  he  knew  absolutely  nothing  of  what  transpired 
in  that  time. 

The  murder  was  committed  in  April,  1901,  and  the 
trial  was  held  in  February,  1902.  In  the  meantime, 
two  certificates — one  from  a  physician,  the  other  from 
a  priest — were  secured  from  Greece,  to  the  effect  that 
the  defendant's  father  was  an  epileptic ;  that  he  often 
had  "nervous  sickness"  and  would  "fall  down  almost 
daily,"  and  that  he  had  been  so  afflicted  for  many 
years. 

I  examined  the  man  and  gave  testimony  in  the  case, 
and  repeated  examinations  made  while  he  was  in  jail 
revealed,  among  other  things,  the  following: 

He  was  born  in  Greece  and  came  to  America  nine  or 
ten  years  previously.  He  spoke  English  quite  per- 
fectly and  understood  readily;  he  answered  questions 
in  a  simple  and  straightforward  way.  Age,  twenty- 
four;  height,  5  feet  two  inches  and  a  half;  weight,  134 
pounds.  Present  occupation,  flower  merchant.  His 
mother  died  in  childbirth ;  his  father  is  living  and  sub- 
ject to  epilepsy;  his  grandparents  lived  to  old  age, 
the  father's  mother  dying  of  epilepsy.  He  has  one 
sister  living  and  well.  There  was  no  history  of  in- 
sanity or  intemperance  in  any  of  his  ancestors  obtain- 
able, although  it  was  stated  that  his  father  became 
mentally  disturbed  at  times  as  the  result  of  his  epilepsy. 

Physiognomy:  The  complexion  was  clear  and  smooth ; 
nutrition  was  good;  the  expression  was  calm  and 
benign;  speech  was  clear  and  distinct,  except  that  the 
English  was  not  perfect.  There  were  no  anatomic 
stigmata  about  the  face,  cranium,  teeth,  palate,  ears, 
or  limbs.  There  was  some  anomaly  of  skin  in  the 
way  .of  dense  hairy  growth  over  the  shoulders,  chest, 
and  arms.  There  were  no  physiologic  stigmata  in  the 
way  of  tremors,  tics,  or  nystagmus ;  nor  was  there  any 
evidence  of  mental  stigmata  of  any  kind.  He  did 
not  appear  to  be  erratic  in  any  way;    was  not  emo- 


PAROXYSMAL    EPILEPTIC    INSANITY.  479 

tional  or  egotistic.  All  superficial  reflexes,  including 
the  plantar,  cremasteric,  abdominal,  epigastric,  and 
scapular,  responded  naturally.  Of  the  deep  reflexes, 
that  of  the  left  patella  was  somewhat  exaggerated, 
those  of  the  wrist  and  elbow  being  normal.  The  left 
pupil  responded  more  slowly  to  light  than  the  right. 
There  was  no  ankle-clonus  and  no  impairment  of 
tactile  sensation  in  any  part  of  the  body.  Vision  and 
taste  were  normal;  hearing  was  defective,  especially  on 
the  right  side.  Measurements  of  the  limbs  showed 
nothing  anomalous.  Power  of  grip  was  coequal,  but 
low  in  both  hands. 

I  was  constantly  impressed  with  the  man's  evident 
honesty  and  sincerity,  and  his  expressions  of  regret 
for  the  crime  appeared  to  be  genuine. 

He  stated  that  the  first  epileptic  seizure  he  had, 
that  he  remembered,  occurred  when  he  was  eight 
years  old,  at  which  time  his  father  told  him  of  a  former 
attack  that  had  occurred  when  he  was  six  years  old. 
On  one  occasion  he  fell  from  a  single  story  window 
while  in  a  fit,  cutting  his  head  in  several  places ;  there 
are  three  small,  star-shaped  scars  on  the  forehead  a 
little  to  the  left  of  the  center,  and  a  fourth  one  in  the 
edge  of  the  hair  above  the  left  temple.  He  described 
an  attack  that  occurred  in  Middletown,  Connecticut, 
in  1895,  when  he  fell  downstairs,  and  others  he  had 
in  jail  after  the  murder,  the  first  occurring  three  weeks 
after  that  event.  The  jailer  testified  that  he  saw  the 
defendant  three  different  times  in  attacks  of  some 
sort,  and,  from  what  I  could  learn  of  them  from  the 
jailer,  it  was  my  belief  that  the  attacks  were  epileptic. 

The  defendant  testified  on  the  stand  that  the  last 
thing  he  remembered  in  the  store — where  the  shooting 
was  done — was  a  feeling  as  though  ' '  a  wave  of  cold 
air  was  creeping  from  his  feet  upward,"  then  his  eyes 
"got  dull  and  flew  about";  he  saw  "yellow,  red,  and 
green,"  after  which  he  remembered  nothing.  He  also 
declared  he  experienced  the  same  sensations  on  the 
occasion  of  the  attack  in  Middletown  in  1895. 

The  question  arose  as  to  the  mental  condition  the 
patient  was  in  when  he  fired  the  shots.  I  stated  it  as 
my  belief  that  if  the  patient  experienced  the  initial 
symptoms    of    an    epileptic    convulsion,    such    as    he 


480         THE    MEDICOLEGAL    ASPECTS    OF    EPILEPSY. 

described  as  being  present  at  the  time,  he  was  in  an 
automatic  or  subconscious  state  when  he  committed 
the  deed  and  could  not,  therefore,  be  held  responsible. 

The  question  then  arose  as  to  whether  a  person  in  a 
complete  state  of  epileptic  automatism  could  receive  a 
mental  impression  that  he  could  retain  and  carry  into 
the  conscious  state  beyond,  and  I  gave  it  as  my  opinion 
that  such  a  thing  would  not  be  possible. 

Then  came  the  question,  "  How  could  the  defendant 
realize  he  had  done  something  wrong  and  seem  to 
regret  it  (as  it  was  claimed  this  man  did,  when  he 
said  shortly  after  the  shooting,  'It's  too  bad;  it's  too 
bad'),  if  he  was  in  an  automatic  state  at  the  time?" 
My  contention  was  that  even  though  the  defendant 
might  have  dimly  realized  at  the  time  that  he  had 
done  wrong,  it  was  no  evidence  of  the  possession  of 
his  mental  faculties,  for  while  in  such  a  state  a  person 
may  be  spoken  to  and  will  correctly  respond,  yet 
retain  no  knowledge  of  it  when  the  subconscious  state 
is  gone. 

After  prolonged  deliberation,  the  jury  returned  a 
verdict  of  manslaughter  in  the  second  degree. 

If  this  man  was  an  epileptic  and  was  under  the 
influence  of  a  seizure  at  the  time  he  committed  the 
deed,  he  should  not  have  been  convicted.  But  in  such 
cases  we  encounter  a  somewhat  anomalous  situation, 
for  while  the  law  recognizes  the  absence  of  responsi- 
bility in  insanity,  it  fails  to  do  so  in  epilepsy,  and  if 
this  man  had  been  found  insane,  he  would  have  been 
committed  to  a  proper  institution,  but  being  an 
epileptic,  he  must  either  be  found  guilty  and  made  to 
suffer  for  his  act,  or  be  acquitted  and  allowed  to  go 
free.  Had  his  defense  been  insanity,  the  verdict,  in 
all  probability,  would  have  been  "guilty,  but  insane." 

Case  II.— C.  F.  C.  In  the  "Journal  of  Mental 
Science"  for  July,  1901,  Percy  Smith,  physician  for 
mental  disorders  at  the  Charing  Cross  Hospital,  reports 
in  detail  the  case  of  a  man  who  murdered  his  wife 
and  child  during  the  night,  who  was  found  the  next 
day  at  noon  sitting  on  a  chair  in  the  middle  of  the 


PAROXYSMAL    EPILEPTIC    INSANITY.  481 

room  in  which  the  bodies  lay,  with  his  night  clothing 
still  on,  his  eyes  closed,  his  head  bent  forward,  and  his 
hands  loosely  in  front  of  him.  An  empty  vial  which 
had  contained  chloroform  and  oil  of  cloves  was  found 
on  the  washstand,  and  there  was  a  smell  of  the  latter 
drug.  There  were  blood-marks  on  the  prisoner's 
clothing  and  on  his  arm. 

'  He  seemed  unconscious,  made  no  reply  when  spoken 
to,  shouted  at,  or  shaken,  or  any  resistance  when  he 
was  laid  on  the  floor  that  he  might  be  dressed  to  be 
taken  to  the  police  station. 

On  arrival  at  the  police  station  at  3.15  p.  m.,  further 
attempts  were  made  to  arouse  him,  and  with  the  idea 
that  he  had  taken  some  poison,  a  stomach-pump  was 
passed,  but  the  fluid  that  was  drawn  off  merely  con- 
tained clear  gastric  juice  and  did  not  smell  of  either 
chloroform  or  oil  of  cloves.  At  the  same  time  he  is 
reported  to  have  said :  "I  have  been  roughly  treated ; 
which  of  my  children  is  dead?"  Two  hours  later  he 
was  examined  again  and  appeared  to  be  thoroughly 
conscious  of  the  position  he  was  in,  and  to  be  sane, 
but  said  he  was  entirely  unconscious  of  anything  that 
had  happened  between  the  time  he  last  applied  the 
chloroform  and  oil  of  cloves  after  going  to  bed,  to 
relieve  a  severe  headache,  and  the  time  when  he  became 
conscious  at  the  police  station  after  the  stomach-pump 
had  been  passed. 

He  burst  into  tears  and  used  many  expressions  of 
endearment  in  regard  to  his  wife  and  child,  adding, 
"We  never  quarreled  in  our  lives.  How  could  I  have 
done  it  ?  I  suffer  very  much  from  my  head ,  especially 
at  night." 

He  was  fifty  years  of  age,  and  had  entered  the  army 
in  1870,  serving  for  many  years  in  Egyptian  cam- 
paigns, and  he  had  been  known  during  that  time  to 
suffer  from  "petit  mat  de  soleil  "  and  "fainting  spells." 
As  a  soldier  his  conduct  had  been  exemplary,  and  he 
had  risen  to  the  highest  rank  obtainable  by  a  non- 
commissioned officer. 

It  was  also  reported  that  he  had  a  sunstroke  shortly 
after  entering  the  army,  which  rendered  him  uncon- 
scious from  noon  one  day  until  the  following  morning, 
and  that  he  became  subject  to  "  fits"  soon  after  that. 
31 


482        THE    MEDICOLEGAL    ASPECTS    OF    EPILEPSY. 

The  physicians  called  to  examine  him  endeavored 
to  establish  his  irresponsibility  on  account  of  epilepsy. 

As  previously  stated,  in  his  charge  to  the  jury  the 
judge  did  not  refer  to  the  rules  in  the  McNaughton 
case,  or  mention  the  question  of  ''right  and  wrong," 
"a  knowledge  of  the  nature  and  quality  of  the  acts 
committed,"  but  stated  that  practically  the  only  ques- 
tion the  jury  had  to  consider  was  whether  the  deed 
had  been  committed  under  circumstances  which  would 
absolve  the  prisoner  from  the  full  consequences  of  the 
crime ;  adding  that  when  the  jury  was  considering  the 
history  of  the  prisoner  they  could  not  shut  their  eyes 
to  the  history  of  the  other  members  of  the  family. 

The  jury  returned  a  verdict  of  "  guilty,  but  insane," 
and  the  prisoner  was  ordered  to  be  detained  during 
the  pleasure  of  the  Government. 

In  marked  contrast  to  the  enlightened  jurisprudence 
principles  manifested  in  this  case,  are  those  in  the 
following : 

Case  III. — (Reported  by  Wise,  "  American  Journal  of 
Insanity,"  Vol.  xlv,  p.  360.)  R.  B.,  a  native  of  Eng- 
land; emigrated  to  the  United  States  at  the  age  of 
nineteen  years.  He  was  indicted  for  murder  in  the 
first  degree  on  March  22,  1888,  being  at  the  time 
twenty-seven  years  old.  His  victim  was  a  married 
woman,  the  wife  of  his  friend.  His  crime  was  charac- 
terized as  "  one  of  the  most  atrocious  and  fiendish  mur- 
ders ever  committed  in  Tompkins  County." 

R.  B.  was  known  to  have  affection  for  his  friend's 
wife.  Though  frugal,  he  bought  her  expensive  pres- 
ents. He  left  his  house  one  evening  to  visit  M.  and 
his  wife.  M.  found  him  later  at  the  back  door  of  his 
(M's.)  house  and  invited  him  in.  They  engaged  in 
conversation  for  an  hour,  M.  asking  him  to  stay  over 
night.  His  wife  had  gone  to  bed  in  an  adjoining 
room.  M.  was  standing  paring  an  apple  to  eat,  and 
started  to  pass  B.,  when  the  latter  made  a  sudden 
assault  upon  him.  M.  afterward  testified:  "  He  struck 
me  on  the  back  of  the  head  three  or  four  times  and 
knocked  me  down  with  something  I  did  not  see.  He 
knocked  me  senseless  on  the  floor.  It  seems  to  me  I 
got  up,  turned  to  him,  and  said,  '  Did  you  strike  me?' 


PAROXYSMAL    EPILEPTIC    INSANITY.  483 

and  he  said  '  No,'  just  as  calm  as  could  be,  and  I  did 
not  know  where  the  blow  came  from.  Then  he  struck 
me  three  or  four  times  and  I  fell  in  an  opposite  direc- 
tion. B.  then  went  to  my  wife's  room  and  began 
pounding  her.  She  hollered  murder  and  screamed 
quite  loud  four  or  five  times.  I  heard  him  continue 
pounding  her." 

M's.  evidence  made  it  appear  that  B.  returned  to 
his  wife's  room,  repeated  the  assault  upon  her,  then 
returned  to  M.,  who  had  crawled  under  a  high-legged 
bureau.  M.  spoke  to  him  but  received  no  reply.  B. 
then  threw  the  hearth  rug  and  some  cushions  over 
M's.  legs,  poured  kerosene  oil  from  the  lamp  over  them 
and  set  them  on  fire.  M.  kicked  them  off.  After 
watching  the  flames  until  they  got  good  headway,  B. 
left  the  house  and  was  next  seen  on  the  highway  less 
than  a  mile  from  the  burning  house.  M.  crawled  out 
of  the  burning  building  to  the  wood  pile  in  the  orchard, 
where  he  was  found  by  neighbors  who  had  been  at- 
tracted by  the  fire. 

A  man  in  a  buggy  discovered  B.  and  asked  him  to 
get  in  and  ride  to  the  village  to  a  dance  with  him. 
B.  made  no  effort  to  escape,  but  accepted  the  invita- 
tion. He  was  immediately  arrested  without  resistance, 
taken  before  M.  and  identified.  Threats  to  lynch  him 
did  not  disturb  him  in  the  least.  When  asked  why  he 
struck  M.  and  his  wife,  he  said,  "  I  do  not  remember 
doing  it,"  sticking  to  this  declaration  throughout.  He 
finally  said,  "  I  must  have  done  it,  as  everybody  tells 
me  I  did." 

He  stated  that  the  last  incident  of  the  evening  he 
remembered  was  eating  apples  with  M.  The  remains 
of  the  murdered  woman  were  found  in  the  burning 
house. 

The  line  of  defense  was  based  chiefly  on  an  inherited 
epileptic  diathesis,  the  prisoner  having  been  epileptic 
until  the  age  of  nine  years ;  on  symptoms  of  nocturnal 
epilepsy  which  had  appeared  during  the  preceding 
winter ;  and  on  the  absence  of  motive. 

The  hypothetic  question  of  the  defendant's  counsel 
is  presented  as  showing  the  substance  of  the  direct 
evidence  bearing  upon  the  prisoner's  responsibility. 

Question:  "The  defendant,  R.   B.,  is  twenty-seven 


484        THE    MEDICOLEGAL    ASPECTS    OF    EPILEPSY. 

years  of  age,  and  unmarried.  He  was  born  at  Billing- 
boro,  England,  and  there  resided  until  nineteen  years 
of  age.  Since  that  time  he  has  resided  in  the  vicinity 
of  Trumansburgh,  N.  Y. 

"Defendant's  great-grandfather  had  hemiplegia,  or 
paralysis,  and  was  to  a  certain  extent  maniacal  pre- 
vious to  his  death.  His  grandfather  was  affected  with 
epilepsy  and  during  one  of  these  attacks  inflicted  great 
injury  upon  a  friend  who  was  trying  to  restrain  him. 
His  father's  brother  was  an  epileptic,  and  died  by 
falling  into  a  ditch  during  an  epileptic  fit.  His  aunt 
was  an  epileptic,  became  insane,  and  was  confined  in 
a  lunatic  asylum  at  Lincolnshire,  England.  Another 
aunt  was  a  confirmed  epileptic.  His  cousin  developed 
epilepsy  at  the  age  of  twenty,  and  had  had  epileptic 
fits  many  times  since;  and  when  he  had  them,  it  re- 
quired several  men  to  hold  him  until  the  attacks  were 
over.  Another  cousin's  two  children  had  been  subject 
to  epilepsy.  His  grandfather's  cousin  had  been  sub- 
ject to  epileptic  fits,  and  committed  suicide  by  hanging. 
The  above-named  persons  were  very  violent  during  the 
attack  of  epilepsy.  His  oldest  sister  died  at  the  age 
of  two  years  in  an  epileptic  fit.  His  sister  next  younger 
than  the  defendant  died  at  the  age  of  ten  months,  in 
an  epileptic  fit.  His  brother,  aged  twenty-three,  had 
epileptic  fits  occasionally,  up  to  the  time  of  his  leaving 
England  three  years  ago.  His  sisters,  aged  respec- 
tively twenty  and  eighteen,  had  suffered  severely  from 
fits  until  about  eight  years  of  age.  His  brother,  aged 
thirteen,  also  had  had  fits  until  he  was  about  eight 
years  old.  His  brother,  aged  twelve,  had  been  subject 
to  fits  all  his  life,  and  these  fits  were  very  violent. 
His  brother,  aged  nine  years,  had  had  epileptic  fits 
until  he  was  eight  years  old.  His  cousin  had  been 
subject  to  epileptic  fits.  The  defendant,  R.  B.,  had 
had  fits,  which  had  been  accompanied  by  delirium  and 
violence  during  the  attack  and  for  a  short  time  after, 
almost  weekly  and  sometimes  several  in  a  week,  until 
he  was  nine  years  old.  That  all  the  above-named 
family  were  at  times  highly  nervous  and  excitable. 
His  grandfather  and  aunt  were  especially  excitable, 
passionate,  and  impatient  of  control  or  contradiction. 
That    a    simple    indisposition    in    the    above-named 


PAROXYSMAL    EPILEPTIC    INSANITY.  485 

family — feverish,  stomachic,  catarrhal  or  otherwise — 
caused  extreme  nervousness,  violence,  and  delirium. 
That  these  convulsive  attacks  rendered  said  B.  tem- 
porarily maniacal,  followed  at  times  by  great  mental 
prostration;  that  he  was  always  very  violent  during 
these  epileptic  attacks  and  had  to  be  restrained  by 
force  to  prevent  his  doing  an  injury  to  himself  and 
others;  the  most  violent  part  of  the  attack  lasting 
about  fifteen  minutes  and  the  entire  attack  about  an 
hour  or  an  hour  and  a  half.  While  in  England  the 
said  B.  was  treated  a  great  many  times  for  epilepsy 
and  convulsive  seizures  by  Thomas  Blasson,  a  physi- 
cian. He  had  over  four  hundred  of  these  attacks 
before  he  was  nine  years  old.  The  said  B.  while  living 
in  England  displayed  a  good-natured,  pleasant  dispo- 
sition, was  very  kind-hearted  and  a  good,  attentive, 
affectionate  son  and  brother.  He  was  temperate, 
steady,  a  regular  attendant  at  church,  and  an  indus- 
trious workman.  During  the  eight  years  B.  resided 
in  this  country,  he  had  worked  industriously  most  of 
the  time  out  of  doors ;  had  been  regular  and  temperate 
in  his  habits,  and  was  much  respected  by  his  acquain- 
tances; had  never  committed  or  was  accused  of  any 
crime,  previous  to  the  present  one.  During  the  winter, 
and  a  year  or  two  before,  he  complained  a  good  deal 
of  pain  in  his  head,  and  was  somewhat  abstracted  and 
moody  and  did  not  associate  with  young  people  to 
any  extent.  He  could  not  sit  in  a  warm  room  for  any 
length  of  time,  and  used  to  sit  in  a  cold  room  or  go  to 
a  chamber  room  by  himself.  The  sheets  of  the  bed 
during  the  winter  were  frequently  soiled  with  blood 
and  water,  and  the  bed  was  frequently  stained,  as 
though  wet  with  urine  and  semen.  During  the  winter 
of  1 887-1 888,  the  defendant  had  been  afflicted  with 
incontinence  of  urine  during  the  night,  although  to 
no  great  extent. 

"That  he  had  been  in  jail  since  the  17th  day  of 
March,  and  that  while  in  jail  he  was  observed  to  have 
an  epileptic  fit,  or  petit  mal,  or  light  epileptic  seizure, 
and  had  displayed  some  fury. 

"Fully  considering  the  above  facts,  the  medical 
history  of  his  family  and  of  the  defendant ;  the  charac- 
ter and  details  of  the  crime;  the  acts  of  the  prisoner 


486        THE    MEDICOLEGAL   ASPECTS    OF    EPILEPSY. 

subsequent  thereto:  What  would  be  your  opinion  as 
an  expert  as  to  the  condition  of  the  accused  at  the 
time  of  the  commission  of  the  crime?" 

Eleven  reputable  physicians  testified  in  substance 
that  the  prisoner,  in  their  opinion,  was  in  an  uncon- 
scious, epileptic,  or  automatic  state  and  was,  therefore, 
not  responsible. 

One  of  the  two  physicians  for  the  prosecution  said 
the  prisoner  "might  or  might  not  be  an  epileptic"; 
the  other  declared  the  question  did  not  change  his 
views — he  thought  the  prisoner  sane. 

In  his  charge  to  the  jury  the  judge  said:  "You  will 
therefore  see  that  there  may  be  a  very  broad  difference 
between  what  medical  men  define  as  insanity  and 
legal  responsibility.  No  matter  how  insane  a  man 
may  be,  no  matter  how  much  under  the  influence  of 
an  epileptic  attack,  or  epileptic  furor,  no  matter  by  what 
force  impelled  resistible  or  irresistible,  if  this  defendant 
at  the  time  he  did  the  act  knew  the  nature  and  quality 
of  the  act,  and  knew  that  it  was  wrong,  then,  gentlemen 
of  the  jury,  he  is,  in  the  eye  of  the  law,  legally  responsi- 
ble for  the  act  that  he  has  done,  and  if  that  act  consti- 
tutes a  crime,  he  must  suffer  the  punishment  which 
the  law  prescribes.  .  .  .  That  it  is  not  necessary 
for  the  people  to  show  to  you  that  there  was  an  ade- 
quate motive  for  this  act.  It  is  not  necessary  for  the 
people  to  show  you  what  his  motive  was,  but  they 
claim  that  the  reason  and  the  method  and  the  plan 
and  design,  apparent  in  the  act  which  he  did,  in 
themselves  indicate  sanity,  and  show  that  there  was 
motive  for  the  act  itself." 

Notwithstanding  the  judge's  clear  and  concise  in- 
structions to  the  jury,  they  returned  a  verdict  of 
"guilty  of  arson  in  the  first  degree."  They  were  re- 
instructed  and  rendered  a  second  verdict  of  "guilty 
of  murder  in  the  first  degree." 

In  polling  the  jury,  one  member  in  answer  to  a 
question,  said,  "Yes,  I  think  her  death  was  caused  by 
burning. ' '  This  is  referred  to  to  show  the  confusion  in 
the  minds  of  the  jury  caused  by  the  intricate  question 
they  were  called  on  to  consider. 

The  prisoner  was  sentenced  to  be  hanged  on  December 
18,   1888.     His  sentence  was  later  commuted  to  life 


PAROXYSMAL    EPILEPTIC    INSANITY.  487 

imprisonment,  and  he  is  now  (October  i,  1903)  in 
prison  at  Auburn,  N.  Y.* 

Case  IV. — Marie  Barbella,  a  young  Italian  woman, 
murdered  her  lover  apparently  in  cold  blood  by  cutting 
his  throat  with  a  razor  in  New  York  in  April,  1895. 
She  was  tried,  convicted,  and  sentenced  to  death  in  the 
electric  chair,  but  so  much  public  interest  finally 
crystallized  about  her  case  that  she  was  granted  a  new 
trial,  which  resulted  in  her  acquittal  and  discharge 
from  custody.  The  plea  of  the  defense  was  insanity 
from  epilepsy. 

I  give  the  full  substance  of  the  hypothetic  question 
asked  of  the  expert  medical  witnesses  for  the  defense, 
for  it  shows  not  only  the  condition  the  defendant  was 
apparently  in  prior  to  and  at  the  time  of  the  crime, 
but  indicates  the  pains  taken  to  establish  her  epileptic 
ancestry.  The  full  elucidation  of  the  family  history 
is  always  a  matter  of  vital  importance  in  medicolegal 
cases  of  this  kind. 

Question:  "Assume  that  a  woman,  X,  was  born 
about  twenty-four  years  ago  in  Italy ;  that  she  was  the 
daughter  of  poor  and  illiterate  parents ;  that  her  pater- 
nal grandfather  was  a  drunkard  of  a  low  order  of 
intelligence ;  that  her  maternal  grandfather  died  about 
forty  years  ago,  and  that  he  was  observed  on  a  number 
of  occasions  to  be  seized  by  fits  in  the  street,  when  he 
would  rush  against  persons  and  attack  them.  That 
these  attacks  were  observed  three  or  four  times  at 
least,  and  that  nobody  provoked  such  acts,  so  far  as 
the  observer  could  ascertain.  That  when  he  had  his 
attacks  he  assumed  a  threatening  position,  but  when 
he  had  no  attacks  he  was  a  very  considerate  man  of 
severe  and  earnest  appearance.  Assume  that  the 
maternal  grandmother  of  this  woman  X  had  an  attack 
of  some  kind  about  a  year  before  her  death,  which 

*  Dr.  Thomas  Blasson,  mentioned  in  the  hypothetic  case,  wrote  to  the 
"American  Journal  of  Insanity"  about  R.  B.,  March  24,  1889,  in  part  as 
follows:  "I  know  the  whole  of  his  family  and  its  pedigree,  and  I  can  posi- 
tively state  that  a  more  complete  vis  consanguinitatis  I  never  saw.  I  brought 
this  poor  wretch  into  the  world  (as  the  saying  is)  and  I  have  been  the  medical 
attendant  of  his  grandfather,  grandmother,  father,  mother,  aunts  and 
uncles,  cousins  and  second  cousins,  for  thirty-three  years,  and  I  never 
knew  a  family  history  so  charged  'up  to  the  hilt'  with  direct  hereditary 
cerebral  diseases." 


488         THE    MEDICOLEGAL    ASPECTS    OF    EPILEPSY. 

occurred  during  the  night;  that  she  was  found  the 
next  morning  with  her  mouth  distorted  and  unable  to 
speak  and  also  unable  to  walk.  That  this  condition 
continued  for  some  two  or  three  months,  when  she 
gradually  recovered.  That  about  a  year  after  the 
first  attack  she  had  a  similar  one,  after  which  she 
lingered  for  about  fifteen  days  in  a  condition  like  that 
after  the  first  attack,  when  she  died.  That  during  her 
life  she  was  much  addicted  to  the  use  of  intoxicating 
liquors,  being  often  in  a  state  of  drunkenness. 

"Assume  that  the  maternal  grandfather  had  one 
brother  who  was  a  hunchback,  and  another  who  was 
an  habitual  drunkard,  and  who  used  to  smash  furniture 
and  everything  that  he  could  lay  a  hand  on,  and  also 
threatened  the  life  of  his  wife. 

"That  the  mother  of  X  had  one  brother,  who  died 
in  convulsions  at  the  age  of  four  years.  That  the 
father  of  X  was  one  of  six  or  seven  children;  that  he 
had  one  brother,  now  living,  who  was  an  habitual 
drunkard ;  that  this  brother  had  a  habit  of  stripping 
off  his  clothes  and  exposing  his  nude  person  in  the 
streets,  sometimes  when  drunk  and  at  other  times 
when  sober;  that  he  had,  on  a  number  of  occasions, 
piled  up  the  furniture  and  other  household  articles  in 
his  house  and  set  fire  to  them. 

"That  of  the  sisters  of  the  father  of  X,  one,  for  a 
very  slight  reason,  used  to  strike  herself  on  the  face 
with  her  fist,  pull  her  hair,  throw  herself  on  the  ground, 
and  turn  over  so  as  to  strike  her  head  against  the 
walls.  That  the  paternal  grandfather  of  X  was  a  man 
accustomed  to  talk  unintelligently  and  irrationally, 
and,  when  spoken  to  appeared  to  have  no  understand- 
ing of  what  had  been  said.  When  told  to  do  a  thing, 
would  do  exactly  the  opposite. 

"Assume  that  the  mother  of  X  was  forty-seven 
years  old;  that  she  was  married  at  the  age  of  fifteen; 
that  she  suffered  from  headache  and  '  a  turning  of  the 
head,'  so  that  she  became  unable  to  talk;  that  she 
often  had  to  take  hold  of  something  to  keep  from 
falling.  That  there  were  moments  when  her  eyes  were 
in  utter  darkness  with  streaks  of  red  and  white  that 
flash  before  them;  that  she  sometimes  had  cramps  in 
the  muscle  of  the  right  leg,  and  then  a  general  painful 


PAROXYSMAL    EPILEPTIC    INSANITY.  489 

contraction  of  the  right  side,  up  to  the  neck,  which 
lasted  a  quarter  of  an  hour  and  more,  and  that  up  to 
within  a  few  years  ago  she  was  accustomed  to  have 
attacks  in  which  she  would  fall  to  the  ground,  have 
convulsions,  and  while  muttering  would  shift  her 
tongue  from  one  side  of  the  mouth  to  the  other;  that 
at  such  times  her  eyes  would  be  wide  open  and  she 
would  stretch  her  arms  and  legs  out  stiff;  that  her 
face  would  be  pale  when  thus  attacked  and  she  would 
be  stupid  when  recovering  from  the  attack ;  that  when 
such  an  attack  was  approaching,  she  would  often  cry 
and  then  fall  to  the  ground. 

"That  these  seizures  came  at  irregular  intervals, 
sometimes  being  several  months  apart,  and  again  at 
much  shorter  intervals. 

"That  the  mother  of  X  has  had  thirteen  children 
and  two  miscarriages,  seven  of  the  children  being  dead, 
and  all  dying  in  convulsions  before  the  age  of  two 
years. 

"That  the  father  of  X  was  about  fifty-eight  years 
of  age ;  that  during  his  early  manhood  up  to  about  his 
thirtieth  year  he  had  been  an  habitual  drunkard ;  that 
he  was  illiterate  and  of  a  low  order  of  intelligence. 
That  the  eldest  brother  of  X  was  twenty-eight  years 
of  age ;  that  up  to  his  seventh  year  he  had  been  liable 
to  convulsions;  that  one  day  when  about  twelve  years 
of  age  he  was  attacked  by  convulsions  and  fell,  striking 
himself  so  that  his  face  bled;  that  he  was  put  to  bed 
and  when  asked  what  the  matter  was,  said  he  '  did 
not  know  anything' ;  that  when  he  lay  on  the  floor  he 
was  of  the  color  of  death,  his  mouth  was  distorted  and 
frothy,  and  he  was  in  a  trembling  condition;  that  after 
he  was  put  on  the  bed,  sleep  intervened  and  lasted 
two  or  three  hours.  When  he  awoke  and  was  asked 
what  the  trouble  was,  replied, '  I  do  not  know  anything. 
I  think  I  had  a  turning  of  the  head  which  caused  my 
accident.'  That  after  this  attack  his  clothes  were 
found  wet  from  micturition.  That  he  had  always  been 
a  light  sleeper,  complaining  of  pains  in  his  head  and 
dizziness. 

"That  the  brother  of  X  next  to  the  one  just  now 
described,  was  now  twenty-one  years  of  age ;  that  he 
could  not  walk  until  about  the  age  of  three ;  that  as  a 


49°         THE    MEDICOLEGAL    ASPECTS    OF    EPILEPSY. 

child  he  had  convulsions,  and  when  about  seven  or  eight 
years  of  age  he  suddenly  fell  on  the  ground  and  hurt 
his  head,  so  that  he  had  to  be  picked  up  and  cared 
for;  that  after  he  had  been  put  upon  a  bed  he  slept 
several  hours,  and  when  asked  what  was  the  trouble, 
was  unable  to  respond  intelligently ;  that  he  had  had 
three  or  four  such  attacks ;  that  he  went  to  school  for 
about  three  years  and  left  because  it  was  too  difficult 
for  him  to  learn ;  that  he  was  subject  to  '  turnings  of 
the  head' ;  that  he  was  a  light  sleeper,  often  not  falling 
asleep  until  morning ;  that  he  was  troubled  with  terri- 
fying dreams — he  constantly  heard  something  like  bells 
ringing  in  his  ears,  and  his  memory  was  very  weak. 

"  That  the  youngest  brother  of  X  was  fourteen  years 
old ;  that  when  an  infant  he  was  afflicted  with  convul- 
sions; that  once  when  about  eight  years  of  age  while 
at  play,  stars  suddenly  came  into  his  eyes,  after  which 
he  could  not  see,  and  fell. 

"That  X  had  a  sister,  now  about  twenty-three  years 
of  age,  who,  from  childhood  up  to  the  age  of  ten,  had 
suffered  with  convulsions;  that  when  about  fourteen 
years  of  age  and  engaged  in  washing,  she  had  '  a  turn- 
ing,' 'a  dizziness,'  and  fell;  that  after  the  feeling  of 
dizziness  she  could  not  see,  and  when  she  got  up  knew 
nothing  of  what  had  happened ;  that  once  she  was  hold- 
ing her  little  brother  in  her  arms,  when  a  dizziness 
overcame  her,  her  arms  loosened,  she  could  not  see, 
and  let  the  child  she  was  holding  fall ;  that  it  was  half 
an  hour  before  she  knew  anything.  When  her  mother 
subsequently  asked,  'Why  did  you  drop  the  child?' 
she  said,  '  I  cannot  remember  anything  about  how  it 
happened.'  That  four  or  five  years  ago  she  found 
herself  on  the  roof  of  a  house,  when  all  at  once  she  saw 
everything  red  and  black  before  her  eyes ;  that  she  was 
interrogated  as  to  what  had  happened  but  did  not 
remember  anything  except  the  feeling  of  dizziness  and 
the  flashes  of  light;  that  on  this  occasion  she  was  ob- 
served to  rush  toward  the  edge  of  the  roof  as  if  she 
intended'  to  throw  herself  down;  that  before  she 
jumped  she  was  seized  and  carried  downstairs  while  in 
contortions.  After  she  came  to  and  was  asked  why 
she  wanted  to  throw  herself  from  the  roof,  she  said 
she  '  didn't  remember  anything  about  it.' 


PAROXYSMAL    EPILEPTIC    INSANITY.  491 

"Assume  that  the  youngest  sister  of  X  was  eleven 
years  old;  was  a  constant  sufferer  from  headaches, 
which  occurred  about  twice  a  week  and  were  often 
accompanied  by  feelings  of  dizziness,  during  which  she 
was  obliged  to  hold  on  to  something  to  prevent  falling ; 
that  about  two  years  ago  while  at  home  her  head  sud- 
denly went  around  and  she  fell  unconscious ;  that  pre- 
ceding this  attack  she  had  a  headache.  When  she 
came  to  and  found  herself  on  a  sofa,  her  mother  asked 
her  what  was  the  trouble,  and  she  replied  that  she  had 
no  recollection  of  what  had  happened  after  she  had 
felt  her  head  going  around ;  that  after  this  attack  her 
clothes  and  the  floor  were  wet  from  micturition. 

"Assume  that  X,  from  the  age  of  about  from  two 
months  to  seven  years,  had  been  afflicted  with  convul- 
sions ;  that  up  to  her  fifth  year  she  wet  her  bed ;  that 
when  she  was  about  four  years  of  age,  she  was  sitting 
on  a  stool  and  suddenly  fell  to  the  floor,  rigid,  shaking, 
and  staring,  with  her  mouth  distorted  and  frothy ;  that 
she  was  picked  up,  afterward  remaining  three  or  four 
hours  in  a  state  of  unconsciousness  or  sleep,  and  on 
awakening  she  was  in  a  state  of  stupidity.  Assume 
that  at  ten  years  of  age  she  was  found  lying  on  the 
ground  bleeding  about  the  face,  with  her  mouth  dis- 
torted and  unconscious;  that  at  this  time  she  cut  her 
forehead,  the  scar  from  which  still  remains;  that  on 
this  occasion  she  was  asked  how  she  had  come  to  be 
upon  the  ground  bleeding,  and  replied  that  she  did  not 
know;  that  when  her  head  became  dizzy,  she  saw 
something  red  like  a  flash  of  light,  and  that  the  next 
thing  she  remembered  was  when  she  found  herself 
upon  her  bed  and  her  mother  asked  her  how  she  got 
on  the  floor;  that  after  the  flash  of  light  appeared, 
she  could  see  nothing,  and  everything  became  black 
before  her  eyes. 

"That  at  the  age  of  about  nineteen,  X  came  from 
Italy  to  America  and  began  work  at  plain  sewing ;  that 
when  about  twenty  years  of  age  she  was  talking  one 
day  with  members  of  her  family,  when  suddenly  she 
uttered  a  scream,  ran  toward  the  window,  and  was  in 
the  act  of  throwing  herself  therefrom,  when  she  was 
prevented  by  a  member  of  the  family;  that  she  was 
then  placed  on  a  chair,  and  at  once  began  to  tremble 


492         THE    MEDICOLEGAL    ASPECTS    OF    EPILEPSY. 

and  shake  all  over,  and  finally  to  knock  her  head 
against  the  wall;  that  she  then  became  relaxed  and 
remained  powerless  until  placed  upon  a  bed,  where 
she  apparently  slept  for  some  hours.  After  awakening 
and  on  being  asked  why  she  had  sought  to  throw  her- 
self from  the  window,  she  answered,  '  You  are  crazy, 
I  don't  remember  that  I  ever  tried  to  throw  myself 
from  the  window' ;  that  prior  to  this  act  she  had  felt 
her  head  'going  around'  and  saw  something  in  her 
eyes  just  as  she  lost  consciousness.  On  a  later  occa- 
sion, she  suddenly  started  to  run  to  the  roof  of  the 
house  and  was  caught  by  her  father  in  time  to  prevent 
her  from  jumping  from  the  roof ;  that  he  took  her  down 
and  placed  her  upon  a  chair,  when  she  then  began  to 
shake,  with  her  arms  stiff  and  her  head  thrown  back- 
ward; that  she  then  seemed  to  fall,  and  awoke  after  a 
couple  of  hours  or  so,  and  when  asked  what  the  trouble 
was,  replied  that  she  did  not  remember  anything. 
That  just  previous  to  this  X  saw  'red  and  black'  and 
felt  something  '  awful  hot'  in  her  head. 

"That  about  three  years  ago  she  met  a  man  who 
became  exceedingly  persistent  in  his  attentions  to  her. 
Up  to  that  time  she  had  had  no  intercourse  of  even  a 
social  nature  with  men  outside  the  members  of  her 
own  immediate  family.  On  or  about  March  28,  1895, 
after  a  pursuit  of  several  months,  after  repeated 
endeavors  on  the  part  of  X  to  avoid  him,  this  man, 
subsequently  deceased,  took  her  into  a  saloon  and 
gave  her  some  liquid  of  a  reddish  color  to  drink,  which 
she  could  smell,  and  which  made  her  immediately  ill, 
and  while  in  that  condition  she  was  carried  by  him 
into  a  room  and  there  dishonored. 

"Assume  that  between  the  time  of  the  aforesaid 
seduction  and  April  26,  1895,  with  the  exception  of 
two  or  three  days  directly  after  the  seduction,  X  lived 
with  this  man  in  his  apartments ;  that  during  this  time 
she  was  possessed  of  one  paramount  idea  and  purpose, 
namely,  to  become  the  wife  of  her  seducer  in  order  to 
be  able  to  return  to  the  home  of  her  parents ;  that  she 
continually  implored  and  prayed  this  man  to  marry 
her  and  save  her  honor.  That  although  often  struck 
and  beaten  by  him,  she  did  not  evince  any  anger  or 
menace   him  in   any   way   whatsoever;  that   her   de- 


PAROXYSMAL    EPILEPTIC    INSANITY.  493 

meanor  and  deportment  during  this  time  were  tearful, 
despairing,  and  beseeching;  that  she  lost  weight  and 
declared  she  would  take  her  life  unless  she  could 
marry  and  return  to  her  parents'  home;  that  during 
this  time  she  was  frequently  seen  sitting  with  arms 
and  hands  folded,  head  down,  unoccupied,  when  sud- 
denly she  would  burst  into  a  fit  of  weeping.  Assume 
that  in  the  hearing  of  X  the  deceased  boasted  of 
seductions  he  had  made  in  cases  other  than  that  of  X ; 
that  he  showed  to  X  pictures  of  other  women  he  had 
ruined,  whose  dishonor  was  his  boast. 

"Assume  that  ten  days  before  the  death  of  her 
seducer  she  was  heard  to  utter  a  scream  and  seen  to 
fall;  that  she  had  twitchings  and  contractions  of  the 
muscles;  her  limbs  and  body  grew  stiff  and  she  was 
placed  upon  a  bed  in  a  seemingly  unconscious  condi- 
tion; that  her  body  lay  rigid  like  a  corpse,  her  face 
white,  with  froth  about  the  mouth,  and  that  she  re- 
mained in  this  condition  for  eight  or  ten  minutes ;  that 
when  she  came  to  she  seemed  dazed  and  stupid,  and 
on  being  questioned  appeared  not  to  know  what  had 
happened  to  her. 

"Assume  that  on  the  morning  of  the  26th  of  April, 
X  and  the  deceased  had  their  usual  discussion  concern- 
ing marriage,  wherein  he  reiterated  his  refusal  to  accede 
to  her  request ;  that  after  this  discussion  the  deceased 
went  to  a  saloon,  two  doors  from  the  house  in  which 
he  and  X  lived;  that  within  a  few  minutes  of  his 
arrival  there  X  entered  the  saloon,  when  she  again 
asked  him  to  marry  her,  and  he  refused ;  that  she  then 
left  the  saloon  and  went  into  the  house  where  she  lived 
to  get  a  piece  of  cloth  for  personal  use  from  her  trunk ; 
that  she  was  seized  with  an  impulse  to  destroy  herself 
and  that  when  her  hand  accidentally  came  in  contact 
with  a  razor,  she  took  it,  not  with  any  intent  of  using 
it  upon  the  deceased,  but  to  assist  her  in  executing  her 
impulse ;  that  she  did  not  remember  where  she  put  the 
razor,  and,  leaving  the  house  with  suicidal  intent  still 
in  mind,  started  to  cross  the  street,  the  saloon  in  which 
she  had  left  the  deceased  being  on  the  same  side  of 
the  street  as  the  house  in  which  she  lived;  that  she 
hesitated  in  the  middle  of  the  street  and  then  returned 
in  the  direction  of  the  saloon  with  the  desire  to  see 


494         THE    MEDICOLEGAL    ASPECTS    OF    EPILEPSY. 

her  seducer  again  before  she  died;  that  when  she  got 
back  to  the  saloon,  she  found  her  mother  there  in 
tearful  conversation  with  her  lover,  beseeching  him  to 
marry  her  daughter,  X ;  that  X  then  said,  '  Don't  cry, 
mother,  perhaps  he  will  marry  me' ;  that  X  was  herself 
in  tears  at  this  time ;  that  the  discussion  as  to  marriage 
continued  between  X,  her  mother,  and  the  deceased; 
that  the  demeanor  of  X  during  this  conversation  was 
tearful,  imploring,  and  sorrowful;  that  the  discussion 
was  carried  on  very  quietly,  and  during  the  course 
of  it  the  deceased  asked  the  defendant's  mother  for 
money,  as  a  price  for  which  to  purchase  his  consent  to 
marry  her  daughter;  that  finally  the  deceased  was 
heard  to  refuse  the  request  of  mother  and  daughter 
and  say,  'Pigs  may  marry,'  or  words  of  like  import; 
that  instantaneously  with  the  uttering  of  these  words 
X  approached  the  deceased  and  inflicted  the  wound 
which  caused  his  death;  that  up  to  the  time  of  the 
infliction  of  this  wound  X  remained  tearful  and  sor- 
rowful in  appearance,  but  at  the  moment  these  words 
were  said  she  shook  all  over,  her  eyes  were  injected 
and  rolling,  her  whole  appearance  changed;  that  she 
was  heard  to  emit  some  sound  or  screech  immediately 
before  the  fatal  act.  She  moved  away  from  him  in  the 
direction  of  the  door  of  the  saloon  and  fell  several  paces 
from  where  she  had  wounded  him,  no  one  being  near 
her  when  she  fell ;  that  the  wound  inflicted  by  her  was 
made  by  a  razor,  beginning  about  two  inches  to  the 
left  of  the  median  line  of  the  neck,  passing  across  the 
neck  backward  up  to  the  bony  prominence  behind  the 
right  ear,  severing  all  the  tissues  in  the  neck  so  as  to 
expose  the  spinal  column.  Directly  subsequent  to  the 
infliction  of  the  fatal  wound,  she,  in  some  way  un- 
known, arose  and  was  next  seen  on  the  sidewalk  in 
front  of  the  saloon,  gesticulating  and  uttering  words 
of  the  following  import:  '  Die,  you  have  taken  my  vir- 
ginity.' That  at  this  time  she  had  froth  about  her 
mouth,  her  face  was  white  and  her  eyes  like  glass  and 
staring;  that  she  was  looking  at  her  blood-stained 
hands  and  rubbing  them  the  one  upon  the  other ;  that 
she  took  up  her  skirt  and  removed  the  foam  or  froth 
from  her  mouth  and  then  put  her  hands  into  a  pail 
of  water  standing  near ;  that  when  she  heard  the  words, 


PAROXYSMAL    EPILEPTIC    INSANITY.  495 

'pigs  may  marry,'  she  felt  something  very  hot  in  her 
head  and  saw  flashes  of  light,  black  and  red,  and  then 
became  blind ;  the  next  sensation  that  she  remembered 
was  when  she  saw  her  hands  covered  with  blood. 
That  she  had  no  recollection  of  having  injured  or 
wounded  the  deceased,  and  thought  that  she  herself  was 
wounded;  that  she  felt  something  in  her  mouth  like 
soap,  which  she  wiped  off  with  her  dress. 

"Assume  that  after  dipping  her  hands  into  water 
as  above  referred  to,  she  entered  a  grocery  store  and 
was  there  taken  into  custody  by  an  officer ;  that  before 
and  after  her  arrest  she  was  passive  and  indifferent, 
making  no  effort  to  escape  or  in  any  way  interfere 
with  the  officers  of  the  law.  Assume  that  after  being 
arrested  she  went  with  the  policeman  to  the  apart- 
ments in  which  she  had  lived,  where  she  removed  her 
waist  and  threw  it  out  of  the  window;  that  while  in 
this  room  she  was  quiet  and  passive,  and  on  arrival  at 
the  station  house  she  still  seemed  unconscious,  as 
though  nothing  had  happened. 

' '  That  while  at  the  police  court  on  the  day  of  the 
homicide,  she  seemed  dazed,  bewildered,  and  irra- 
tional, sitting  fifteen  minutes  in  a  chair  almost  motion- 
less, with  her  eyes  half  closed,  fixed  and  staring;  that 
she  was  addressed  through  an  interpreter  during  this 
time  and  it  was  only  after  repeated  questions  that  an 
answer  or  an  apparent  answer  could  be  elicited;  that 
as  soon  as  she  would  seem  to  recover  from  her  condi- 
tion of  apparent  stupor  and  respond  to  a  query,  she 
would  again  relapse  into  the  condition  above  described ; 
that  on  the  day  of  the  homicide  or  shortly  thereafter, 
and  for  a  period  of  about  two  and  a  half  months  she 
was  confined  in  prison,  awaiting  trial,  during  which 
period  her  condition  was  almost  uniformly  that  of  one 
dazed  and  stupefied,  except  that  at  not  infrequent 
intervals  she  would  have  fits  of  weeping,  would  refuse 
food  to  a  marked  degree  and  suffered  from  sleeplessness. 

"Assume  that  she  was  tried  for  the  murder  of  her 
seducer  on  July  8,  1895,  and  the  days  following;  that 
during  the  progress  of  the  trial  she  was  nervous  and 
otherwise  perturbed  to  such  a  degree  that  the  trial  had 
to  be  stopped  in  at  least  three  instances  before  she 
recovered  sufficiently  to  have  the  trial  proceed;  that 


496         THE    MEDICOLEGAL    ASPECTS    OF    EPILEPSY. 

she  was  immediately,  after  the  conclusion  of  this  trial, 
taken  to  prison,  there  to  await  the  result  of  an  appeal 
which  had  been  taken  from  the  judgment  of  conviction. 
Assume  that  during  her  ten  months'  stay  in  prison 
her  life  was  marked  by  symptoms  of  confusion  and 
dullness  at  first,  accompanied  by  bursts  of  weeping 
and  later  by  a  more  conscious  and  continuous  sorrow 
and  despair;  and  that  in  April  of  1896,  when  told  she 
was  to  have  a  new  trial,  she  seemed  totally  uninter- 
ested and  indifferent  at  the  news.  That  she  had  no 
recollection  of  the  killing  of  her  seducer,  and  knew  that 
he  had  been  wounded  and  had  died  only  through  in- 
formation received  by  her  from  others. 

"Assuming  the  statements  in  that  question  to  be 
true:  Are  you -of  the  opinion,  or  are  you  not  of  the 
opinion,  that  on  the  26th  of  April,  1895,  at  the  time 
of  the  killing  of  the  deceased  by  the  defendant,  that 
this  defendant  was  able  to  discriminate  between  right 
and  wrong,  or  to  know  the  nature  and  quality  of  the 
act  she  was  doing? 

"  Answer:  I  am  of  the  opinion  that  she  was  not  able 
to  do  that." 

The  same  question  was  answered  in  the  negative  by 
a  large  number  of  prominent  alienists  called  by  the 
defense. 

Murder  by  an  epileptic  (Clouston)  should  usually  be 
looked  upon  as  being  as  much  a  symptom  of  his  disease 
as  larceny  by  a  general  paretic. 

Impulsiveness  is  the  dominant  feature  of  most  of  the 
serious  crimes  committed  by  epileptics.  Motive,  as 
well  as  premeditation,  is  generally  lacking.  In  many 
homicidal  acts  committed  by  epileptics,  consciousness 
is  retained  and  memory  may  not  be  destroyed,  at  any 
rate  not  immediately,  although  subsequently  all  recol- 
lection of  the  deed  is  lost. 

Amnesia  should  not  be  confused  with  unconscious- 
ness in  such  cases.  The  two  are  not  identical ;  uncon- 
sciousness being  a  cessation  of  all  psychic  activity, 
naturally  includes  amnesia,  while  the  latter  does  not 
necessarily  include  the  former. 


POST-EPILEPTIC    AUTOMATISM.  497 

The  retention  of  consciousness  (Baker)  and  even 
memory  is,  perhaps,  most  often  seen  in  cases  in  which 
there  exists  a  pre-epileptic  condition  of  suspicious 
or  smouldering  hatred  fanned  into  the  highest  intensity 
in  the  post-epileptic  state.  Consciousness  and  memory 
are  not,  therefore,  inconsistent  with  epileptic  furor. 

In  post-epileptic  automatism,  amnesia  is  usually 
complete,  though  in  some  cases  there  may  be  a  glim- 
mering of  consciousness  resulting  in  the  memory  of 
certain  things  here  and  there  that  occurred  during  such 
state.  (This  is  illustrated  in  the  case  of  A.  T.  men- 
tioned in  the  preceding  chapter.)  When  things  are 
remembered  in  part,  the  amnesic  state  is  not  complete, 
and  in  such  form  it  is  usually  accompanied  by  some 
degree  of  psychomotor  violence.  Generally  the  vio- 
lence is  intense  and  may  be  prolonged  for  hours.  It 
has  been  my  observation  that  complete  amnesic  states 
are  more  often  characterized  by  comparative  silence; 
at  least  there  is  no  movement  or  commotion  in  them 
that  could  be  regarded  as  pathologic. 

Many  epileptics  suffer  from  post-convulsive  autom- 
atism in  a  manner  not  recognizable  by  the  unskilled 
observer.  I  have  previously  cited  numerous  instances 
of  the  kind.  Crimes  committed  in  such  states  are 
essentially  beyond  the  knowledge  of  the  individual  who 
commits  them. 

Dr.  Orange  (Peterson  and  Haines)  relates  the  case 
of  a  mother  "who,  while  cutting  bread  for  her  family, 
having  her  baby  on  her  arm,  became  momentarily 
unconscious.  On  return  of  consciousness  she  pro- 
ceeded in  an  automatic  way  to  use  the  knife,  not  upon 
the  loaf  but  upon  her  child,  whose  arm  she  amputated. " 

Premeditated  criminal  acts  by  epileptics  are  not  com- 
mon, though  I  recall  several  cases  in  which  the  motive 
was  flimsy  and  the  degree  of  injury  sought  to  be 
inflicted  out  of  all  proportion  to  the  apparent  sense  of 
personal  grievance  the  epileptic  based  his  assault  upon. 

32 


498        THE    MEDICOLEGAL    ASPECTS    OF    EPILEPSY. 

A  male  epileptic  at  the  Colony  got  out  of  bed  too 
early  one  morning  and  was  told  by  the  nurse  to  go 
back.  The  patient  objected  and  the  nurse  insisted. 
The  nurse  left  the  room  for  a  few  moments,  and  on 
returning  found  the  patient  sitting  on  the  bed  trying 
to  conceal  something  under  the  covering.  When  the 
nurse  asked  what  it  was,  the  patient  sprang  at  him 
and  viciously  stabbed  him  with  a  knife.  It  could  not 
be  determined  that  the  patient  had  suffered  from  a 
seizure  just  before  the  assault,  but  his  radical  and 
sudden  change  in  conduct  led  to  such  a  belief.  He  had 
full  subsequent  recollection  of  the  event.  If  he  did 
not  have  a  seizure  just  before  the  assault,  it  was  com- 
mitted under  the  duress  of  epileptic  frenzy,  a  state 
characterized  by  absolute  loss  of  inhibition. 

Another  patient  started  into  the  dining-room  with 
trouser  guards  about  his  ankles.  He  was  requested 
by  the  attendant  to  remove  them,  but  profanely 
refused.  On  being  sent  away  from  the  room,  he  turned 
as  though  to  obey,  but  suddenly  drew  a  knife,  whirled 
around  and  stabbed  the'  nurse  in  the  shoulder,  repeat- 
ing the  blow  as  the  nurse  turned  to  face  him. 

An  asylum  physician  in  France  going  his  rounds 
stopped  to  talk  with  a  male  epileptic  employed  as  a 
tailor.  The  physician  was  stooping  to  examine  the 
patient's  leg,  as  he  complained  of  pain  in  it.  Sud- 
denly the  man  passed  his  arm  around  the  physician's 
neck,  and  thrust  his  long  tailor's  scissors  into  his  side, 
causing  death.  The  act  was  without  motive.  ("  Ameri- 
can Journal  of  Insanity,"  Vol.  xiv,  p.  309.) 

A  woman  of  twenty  years,  whose  grand  mat  attacks 
all  occurred  at  night,  constantly  manifested  a  most 
vicious  disposition.  On  several  occasions  she  assaulted 
nurses  and  fellow-patients  weaker  physically  than 
herself,  always  choosing  a  time  when  her  victim  was 
alone.  On  one  occasion,  she  threw  an  irritating 
washing-powder  in  the  attendant's  eyes,  preliminary 


EPILEPSY    DUE    TO    ACCIDENT    OR    INJURY.  499 

to  an  attempt  to  throw  her  from  a  window.  When 
accused,  she  tearfully  protested  her  innocence.  She 
was  later  committed  as  insane. 

Article  64  of  the  French  penal  code  contains  this 
paragraph  in  reference  to  mental  affections:  "There 
can  be  neither  crime  nor  offence  when  the  accused  was 
in  a  state  of  dementia  at  the  time  of  the  act,  or  when 
he  was  restrained  by  a  force  which  he  was  powerless  to 
resist"  (Fere). 

This  is  an  admirable  provision  for  the  protection  of 
the  epileptic  who  unwittingly  commits  a  crime  while 
under  the  overpowering  duress  of  his  disease. 

The  French  Society  of  Legal  Medicine  recommended 
in  1875  that  the  general  rules  governing  the  exami- 
nation into  the  responsibility  of  the  insane  likewise 
apply  to  epilepsy.  We  cannot  protest  too  earnestly 
against  the  legal  inequality  established  in  favor  of  the 
insane. 

Epilepsy  due  to  accident  or  injury  may  be  a  basis  for 
legal  claim  for  damages.  Pearce  Bailey  *  very  lucidly 
discusses  the  features  of  this  contingency  in  substance 
as  follows : 

It  may  be  easy  or  exceedingly  difficult  to  establish 
causal  relationship  between  an  injury  and  epilepsy.  If 
there  is  evidence  of  a  fracture  of  the  skull,  the  matter 
will  be  simpler  than  when  no  evidence  of  injury  exists. 
It  must  be  shown  that  the  patient  never  had  convul- 
sions prior  to  the  receipt  of  the  injury,  except  such  as 
may  have  occurred  in  infancy  and  which  are  not  re- 
garded as  an  expression  of  idiopathic  epilepsy. 

Alcoholism  and  other  degenerative  conditions  that 
may  have  existed  immediately  before  the  injury  must 
be  considered,  especially  if  the  injury  is  supposed  to 
have  been  slight. 

If  the  injury  results  in  hemiplegia  or  monoplegia 
with  convulsions  following,  the  cause  is  plain;  or  if 

*  "Accident  and  Injury,"  1898,  p.  134. 


5<DO         THE    MEDICOLEGAL    ASPECTS    OF    EPILEPSY. 

the  seizures  are  local  and  so  indicative  of  localized 
brain  lesion,  there  will  rarely  be  any  question  as  to 
their  traumatic  origin. 

The  time  elapsing  between  the  receipt  of  the  injury 
and  the  first  epileptic  manifestations  play  little  part 
in  diagnosis.  Competent  statistics  show  a  wide  varia- 
tion in  this  respect.  In  some  the  seizures  appear 
immediately;  in  others,  not  for  months  or  possibly  not 
until  years  after  degenerative  changes  have  become 
definitely  established. 

In  some  cases  age  may  assist  in  diagnosis.  Idio- 
pathic epilepsy  is  essentially  a  disease  of  early  life. 

Bailey  remarks,  in  conclusion,  that  "no  case  of  epi- 
lepsy in  which  there  is  any  question  of  operation  or  of 
medicolegal  inquiry  should  be  accepted  as  traumatic, 
unless  the  seizure  has  been  witnessed  by  a  physician  or 
by  some  person  trained  in  the  observation  of  the  symp- 
toms of  the  disease.  Such  observations  can  best  be 
carried  out  in  a  hospital." 

Epilepsy  and  Life  Insurance, — The  medical  jurispru- 
dence of  life  insurance  in  its  application  to  epilepsy 
may  seek  to  distinguish  between  "fits"  and  epileptic 
convulsions.  In  Hamilton's  "System  of  Legal  Medi- 
cine ' '  we  find  this :  ' '  The  term  '  fits '  is  so  vague  that 
it  has  no  standing  medically.  The  present  tendency  is 
to  construe  it  as  referring  to  epileptic  convulsions  alone. 
In  the  old  application,  some  importance  was  attached 
to  it.  As  the  distinction  between  the  different  varieties 
of  spasms  was  not  then  understood,  the  term  probably 
included  other  convulsions  than  epileptic." 

One  Griswold  (Chattock  vs.  Shawe  et  al.,  "3  Bige- 
low's  Life  and  Acct.  Ins.  Rep.,"  10)  was  insured  in 
1 83 1,  stating  at  the  time  that  he  was  "in  a  sound  and 
perfect  state  of  health,  and  had  not  been  afflicted  with 
or  was  subject  to     .  fits,  etc." 

It  was  proved  that  he  had  had  two  fits  of  an  epileptic 


TESTAMENTARY    CAPACITY    OF    EPILEPTICS.         501 

character  in  1827,  but  testimony  was  offered  to  show 
that  they  were  the  result  of  an  injury  to  the  head. 

In  his  charge  to  the  jury  the  judge  said :  "  The  inter- 
pretation I  put  on  a  claim  of  this  kind  is,  not  that  the 
party  never  accidentally  had  a  fit,  but  that  he  was 
not,  at  the  time  of  the  insurance  being  made,  a  person 
habitually  or  constitutionally  afflicted  with  fits,  or  a 
person  liable  to  fits  from  some  peculiarity  of  tempera- 
ment, either  natural  or  contracted  from  some  cause  or 
other  during  life." 

The  extraordinary  features  of  this  charge  become 
apparent  when  we  recall  the  frequency  of  trauma  as  a 
cause  of  epilepsy. 

Some  life  insurance  companies  issue  standard  policies 
to  persons  medically  regarded  as  having  under-average 
lives.  Epileptics  belong  to  this  class.  The  average 
life  of  those  having  grand  mat  is  shorter  than  those 
having  petit  mat  attacks.  The  specific  form  of  the 
disease  fixes  the  rate  of  insurance  premiums,  which  in 
any  epileptic  is  higher  than  in  non-epileptics.  Other 
companies  refuse  to  insure  epileptics  at  all,  and  hold 
that  epilepsy  concealed  from  the  company's  knowledge, 
when  the  policy  is  issued,  is  sufficient  to  invalidate  the 
same. 

The  testamentary  capacity  of  epileptics  may  be  ques- 
tioned in  relation  to  the  execution  of  wills.  Hamilton  * 
cites  the  case  of  a  male  epileptic  who  made  his  will 
during  the  inter-paroxysmal  period  and  was  sustained. 
The  testator,  who  was  subject  to  attacks  of  acute 
mania  due  to  epilepsy,  was  committed  to  a  lunatic 
asylum  on  April  29,  1879,  and  discharged  May  12,  1879. 
The  superintendent  of  the  asylum  testified  that  the 
testator's  mental  condition  was  then  good,  and  that 
during  the  interval  between  his  attacks  he  possessed 
sufficient  mental  soundness  to  understand  what  he 
was  doing. 

*  "System  of  Legal  Medicine,"  Vol.  n,  p.  122. 


502         THE    MEDICOLEGAL    ASPECTS    OF    EPILEPSY. 

The  testator  executed  his  will  May  21,  1879.  His 
family  physician  testified  that  he  was  of  sound  mind 
and  memory  and  capable  of  making  a  will. 

He  was  again  attacked  with  an  epileptic  convulsion 
on  June  11,  1879,  and  died  June  24,  1879.  It  was  held 
that  the  testator  was  sane  at  the  time  the  will  was 
made. 

Hamilton  {op.  cit.)  mentions  another  case  in  which 
a  woman  had  an  epileptic  fit  at  the  age  of  sixty-two, 
which  rendered  her  unconscious.  This  was  followed 
by  pneumonia  accompanied  by  high  fever  and  delirium 
which  also  produced  unconsciousness.  She  had  pre- 
viously been  robust  and  intelligent. 

Witnesses  who  were  present  during  her  illness 
stated  that  while  occasionally  out  of  her  mind,  she 
was  at  other  times  rational  and  intelligent,  her  mental 
condition  being  clearly  the  result  of  delirium  attendant 
on  high  fever.  No  witness  claimed  that  she  had  wholly 
lost  her  reason  at  that  period. 

She  executed  her  will  on  November  23,  1868,  and 
made  three  codicils  between  that  time  and  her  death, 
which  occurred  in  July,  1875.  Witnesses  to  the  will 
and  codicils  testified  to  her  sanity  at  the  time  she 
executed  them. 

When  the  case  was  tried  in  the  Circuit  Court  of  St. 
Clair  County,  in  April,  1877,  the  jury  found  that  she 
was  insane  at  the  time  the  will  and  codicils  were 
executed,  which  rendered  them  null  and  void.  This 
finding  was  reversed  on  appeal  to  the  Supreme  Court 
(Brown  tas.  Reggin,  94  111.  R.  560). 

The  only  way  in  which  physicians  can  give  testimony 
of  value  in  such  cases  is  for  them  to  possess  a  thorough 
knowledge  of  the  manner  and  extent  to  which  epilepsy 
may  affect  intelligence  temporarily  or  permanently. 

Some  epileptics  are  clearly  competent  during  the 
inter-paroxysmal  period  to  execute  instruments  whose 
purport  is  obvious  to  them  at  the  moment.     It  does 


TESTAMENTARY    CAPACITY    OF    EPILEPTICS. 


503 


not  follow,  however,  in  any  case  that  the  epileptic's 
action  in  such  a  matter  may  be  remembered  by  him 
for  any  length  of  time  afterward.  A  seizure  occurring 
immediately  after  may  efface  the  memory  of  it  as 
completely  as  though  it  had  never  been  received. 

One  of  the  most  difficult  questions  to  solve  in  respect 
to  the  testamentary  capacity  of  epileptics  pertains  to 
the  presence  of  amnesic  states  that  come  and  go  without 
any  commotion  whatever,  and  that  may  even  escape 
the  observation  of  those  who  may  have  the  individual 
in  view  at  the  moment.  These  states  may  be  pro- 
longed for  indefinite  periods,  during  which  the  person 
acts  in  so  nearly  a  normal  manner  as  to  be  apparently 
under  the  guidance  of  full  judgment  and  reason. 

In  addition  to  this  periodic  loss  of  conscious  action, 
the  majority  of  epileptics  sooner  or  later  attain  some 
degree  of  mental  impairment.  To  show  in  part  the 
extent  to  which  such  impairment  prevails,  I  present 
the  results  of  a  simple  though  effective  test  made  at 
the  Craig  Colony  in  relation  to  the  general  intelligence 
of  801  epileptics. 

TABLE   SHOWING   THE   RESULTS    OF  TESTS    OF  THE   GEN- 
ERAL INTELLIGENCE  IN  801  PATIENTS  AT  THE 
CRAIG  COLONY,  OCTOBER  1,  1903. 


Can  the  patient 
tell 


158 
132 
120 


f  name 

age 

year 

month 

day  of  week 

when  born  

in  what  year  born 
name  of  last  resi- 
dence   j  363  I  100 

name  of  institution  348  115 

how  long  here 320  143 

sign  name 331  132 


Yes. 


441 

357 

312 

3°5 
343 


Men. 


No.  Total 


271  I  192 


2  2   463 
I06   463 

JS1  463 


463 
463 
463 
463 

463 
463 
463 
463 


Women. 


Yes. 


3*9 
278 
222 

233 
244 
220 
152 

255 
234 
233 
246 


No. 


19 

60 

Il6 

I°5 

94 

118 

186 

83 
104 

i°5 
92 


Total. 


338 
338 
338 
338 
338 
338 
338 

338 

338 
338 
338 


504        THE    MEDICOLEGAL    ASPECTS    OF    EPILEPSY. 

The  preceding  table  shows  that  out  of  801  patients 
at  the  Colony  on  October  1st,  41  could  not  tell  their 
names;  166,  their  age;  267,  the  year;  263,  the  month; 
226,  the  day  of  the  week;  238,  when  they  were  born; 
378,  the  year  of  their  birth;  183,  their  last  place  of 
residence;  219,  the  name  of  the  institution  they  were 
in ;  248,  the  length  of  time  they  had  been  there ;  while 
224  could  not  write  well  enough  to  sign  their  names. 


INDEX. 


Abdominal  section,  426 
after-treatment,  432 
anesthesia  for,  430 
closure  of  incision,  431 
drug  treatment  after,  432 
indications  for,  426 
modus  operandi,  430 
preparation    of    assistants, 
429 
of  operator,  429 
of  patient,  428 
results,  432 
technic,  428 
Abortive  epilepsy,  definition,  25 
Accidental  epilepsy  after  twen- 
tieth,    year,     cases     em- 
braced, 32 
cases  embraced,  31 
infantile,    cases    embraced, 

31 
Accidents,  death  from,  305 
epilepsy  due  to,  medicolegal 
aspects,  499 
Acetanilid,  384 
Acetone  in  etiology  of  epilepsy, 

329 
Acne  from  bromid,  365 

prevention  of,  368,  369 
Acromegaly,     Jacksonian     epi- 
lepsy and,  186 
Acute  epilepsy,  195.       See  also 
Status  epilepticus 
infantile   epilepsy,    definition, 

25 
Age,  average,  at  death,  308 
classification  based  on,  30 
mental    condition    and,    rela- 
tion, 299 
of  occurrence  of  epilepsy,  47 
influence  of  heredity  on, 

5.1,  71 
prognosis  and,  298 
status  epilepticus  and,   198 
tendency    of    disease    to    de- 
crease with,   50 
Alcoholic  epilepsy,  definition,  25 
Alcoholism    as    hereditary    fac- 
tor, 67 


Alcoholism,  epilepsy  and,  differ- 
entiation, 279,  285 
Alimentary     canal,     action     of 

bromid  on,  364 
Amaurosis  epileptica,  226,  269 
Ammonia  in  status,   211 
Amnesia  in  epilepsy,  496 

testamentary  capacity  and, 

5°3 
in  post-epileptic  automatism, 

497 

Amyl  hydrate  in  status,  213 
nitrate    in    psychic    epilepsy, 
212 
in  status,  212 

Amylene  hydrate,  377 

Analepsia,   13 

Anatomic  stigmata  of  degenera- 
tion, 44 

Anesthesia  for   abdominal   sec- 
tion, 430 

Angina     pectoris     or     epileptic 
equivalent,   177 

Anisometropic    defects    in    epi- 
leptics, 390 

Anti-autocytotoxin  in  epilepsy, 

329 
Antipyrin,  384 
Antispasmodics  in  status,  210 
Anxiety,  prolonged,  in  etiology 

of  epilepsy,  99 
Apoplexia  parva,   13 
Asafetida  in  status,  212 
Asphyxia    in    etiology    of    epi- 
lepsy,  133 
Asthma,  epilepsy  and,  245 
Asthmatic     affections     as     epi- 
leptic equivalents,  178 
Astigmatism  in  epileptics,  390 
Asymmetries,     facial,     in     epi- 
lepsy,  313 
Atropin  in  status,  212 
Attacks,   character  of,   progno- 
sis and,   300 
frequency  of,   193 

prognosis  and,  300 
isolated,     body-temperature, 
261,  268 


5°5 


506 


INDEX. 


Attacks,  mixed,  22 
prevention  of,   359 
serial,   161.       See  also  Serial 

attacks 
status    epilepticus    and,     in- 
terval between,  199 
suffocation  during,  361 
time  of,   193 

prognosis  and,   300 
treatment  during,  361 
Auditory  epilepsy,  definition,  25 

epileptic  aura,  228 
Aura,     amaurosis,     temporary, 

as,  226 
asthma  and,  245 
auditory,   22S 

blindness,  temporary,  as,  226 
circulation  in,   232 
classification,   223 
deafness  as,   230 
diplopia  as,   227 
double  vision  as,   227 
epigastric,   232 

flatulence  in,  233 

indigestion  in,   233 

statistics,   234 
fear  in,   238 

Fere's  classification,   225 
forms  of,   221 
Gowers'   classification,   224 
imagination  in,   237 
irregular,   223,   243 
meaning,   221 
motor,   223,   239 

trembling  in,   242 
origin  of  cause  of  spasm,  221 
peripheral   injury  and,    222 
prognosis  and,  303 
psychic,   223,   237 
psycho- visual,   228 
respiration  in,   232 
running  in,   240 
sensory,  223,  225 
significance,  221 
smell,  230 
somnolence  as,  243 
taste,  230 

temperature  in,  245 
vagus  nerve  in,  232 
visual,  225 

forms  of,  226 

psycho-,   228 
Voisin's   classification,    225 
whistling  as,   229 
Auricular     epilepsy,     operation 

for,  402 
Autocytotoxin  in  epilepsy,  329 
Automatism,  epileptic,  442 

medicolegal     aspects,    444, 
497 


Automatism,  epileptic,  mental 
state  in,  439 

Autotoxic  theory  of  convul- 
sion, 321,  322 

Bee  stinging  in  etiology  of 
epilepsy,   134 

Belladonna  in  status,  212 
with  bromids,   370 

Bicarbonate  of  soda  with  bro- 
mids, 370 

Blindness,  temporary,  as  aura, 
226 

Blood   after   convulsion,    270 
alkalinity   of,    diminution   of, 

329 
in   convulsions,    hypotoxicity 
of,  328 
Blood-letting  in  status,  210 
Blood-pressure,  convulsion  and, 
271 
diagnostic  value,  273 
Body    fluids,     toxicity     of,     in 

epilepsy,  328 
Body-temperature     after     con- 
vulsion, 260 
toxins  and,  268 
Bonjeon's  ergotin  in  status,  213 
Borax,  375 

Brain,  bulging  of,  into  trephine 
opening,  422 
carcinomata   of,    in   epilepsy, 

320 
changes  in,  in  epilepsy,  316 
cortex     of,     bromid     locally, 
effect,  324 
cell  changes  in,  62,  321,  325 
cocainization  of,  effect,  324 
electric  irritability,  310 
faradization    of,    to    locate 

controlling  center,  424 
scars  of,  removal,  423 
cyst  of,  in  epilepsy,  319 

removal,  423 
development,    gross,    anoma- 
lies of,  312 
gliomata  of,  in  epilepsy,   320 
growths  in,  evidence,  422 

gold  foil  after  removal,  425 
hypertrophy    of,    in    etiology 

of  epilepsy,  131 
macroscopic     lesions     of,     in 

epilepsy,  316 
palsies  as  etiologic  factor,  74 
sarcomata  of,  in  epilepsy,  320 
syphilis  in  etiology  of  epi- 
lepsy, 122 
traumatic  injuries  of,  epi- 
lepsy from,    10 1 


INDEX. 


507 


Brain  tumor  in  epilepsy,  319 
vascular  lesions  of,  in  epilepsy, 

3*9 

Breakfast   menu  for  epileptics, 

355     • 
Bromethyl  in  status,   212 
Bromid,  abuse  of,  365,  366 
acne  from,   365 

prevention  of,  36S,  369 
action  of,  372 

on  cortical  cells,  330 
administration    of,    judicious, 
366 
time  for,  367 
belladonna  with,  370 
codein  with,   375 
effect    on    alimentary    canal, 

364 
on  circulation,   364 
on  cortex,   applied  locally, 

324 
on  nutrition,  364 
on  respiration,   364 
on  skin,   365 
on  spinal  cord,   364 
on  temperature,   364 
hypodermic  use,  369 
in  grand  mal  seizure,   367 
in  emergency,  366 
in  psychic  epilepsy,   366 
in  treatment,  363 

coefficient  forms,  369 
physiologic  action,   363 
intoxication,     prevention    of, 

368-   369 
liquor  potassii  arsenitis  with, 

37° 
trinitrini  with,   378 
of  potassium,  effect    on  ner- 
vous system,  363 
of  sodium,   370 
of  strontium,   370 
pathogenesis  and,   330 
prognosis  and,   291 
reduction  of  dose,   368 
soda  bicarbonate  with,   370 
tissue  waste  and,  365 
Bromid-opium  treatment,  373 
Bromin  preparations,  action  of, 

372 
in  treatment,  363 
special,  371 
Bromipin,   371 
Bromism  in  epilepsy,  365 
Buccal  cavity,  disorders  of,  in 

etiology  of  epilepsy,   no 
Buildings   required   for  Colony, 

343 
Burns   during  convulsions,    250 


Calcareous      degeneration     of 

dura,  314 
Camphor  in  status  epilepticus, 

211 

Carcinomata    of    brain    in    epi- 
lepsy, 320 
Cardiac    disease   in   etiology   of 

epilepsy,   125 
Caries,    dental,    in    etiology    of 

epilepsy,   no 
Catamenia,   prognosis  and,   301 
Cathartics  in  status,  210,  211 
Central    nervous    system,    focal 

lesions  of,  in  etiology,  133 
Cerebral  cortex,  bromid  locally, 
effect,  324 
cell  changes  in,  62,  321,  325 
cocainization      of,      effect, 

324 
electric  irritability  of,   310 
cysts,  removal,  423 
diplegia  in  epilepsy,  316 
infantile  lesions  of,  in  epi- 
lepsy, 316 
embolism,  epilepsy  from,  321 
growth,  evidence  of,  422 
gunshot      wounds,      epilepsy 

from,   102 
hemiplegia  in  epilepsy,  316 
infantile,  lesions  of,  in  epi- 
lepsy, 316 
hemorrhage,     epilepsy    from, 

75.  321 
traumatic,    epilepsy    from, 
102 
hypertrophy    in    etiology    of 

epilepsy,   131 
palsy   as   etiologic   factor,    74 
infantile,   nature  of  lesion, 

syphilis     in,     congenital, 

3l8  ,        . 

syphilis    in    etiology    of    epi- 
lepsy,  122 
Cerebronervous  system,  division 

of,  as  diagnostic  aid,  35 
Cerebrospinal  fluid,  increase  of, 
315 
nervous  system,  divisions  of, 

i°5  ,     . 

Cerebrum,  traumatic  lesions  of, 

epilepsy  from,  10 1 
Cervical  sympathetic,  resection 

of,  in  treatment,  402 
Chemocephalus,  43 
Chiene's    method     of    marking 

fissure  of  Rolando,  418 
Children,     epileptic,     education 

of,  349 


5o8 


INDEX. 


Chloral  hydrate,   376 

in  status,   214 
Chloretone,   379 
in  status,  215 
Chloroform,   384 

in  status,  210,  213 
Chromatolysis"  following  seizure, 

326 
Cigarette    smoking   in    etiology 

.of  epilepsy,  114 
Circular  insanity,  440,  460 
Circulation     after     convulsions, 
271 
effect  of  bromids  on,   364 
in  epilepsy,   232 
Claims     for     epilepsy     due     to 

accident,  499 
Classification,   18 
based  on  age,  30 
on  etiology,  23 

according  to  age,  30 
on  symptomatology,   18 
Nothnagel's,   28 
of  stigmata  of  degeneration, 

43-45 
practical,   30 
Clinical   view   of   newer   patho- 
logic findings,   329 
Clinico-pathologic      guides      to 

operation,   395 
Coal-tax:  derivatives,  384 
Cocain  in  etiology  of  epilepsy, 
136 
locally,  effect  on  cortex,  324 
Codein,   375 

Colony,  advantages  of,   340 
life,   339 

confinement   and  freedom, 

342 
educational        advantages, 
34o,  342 
model,  buildings  required,  343 
purposes  of,  340 
site  of,   341 
Coma     in     status     epilepticus, 

treatment,   215 
Concurrent  disease,  influence  on 

epilepsy,  386 
Confinement     and    freedom    in 

Colony,   342 
Congenital  causes,  definition,  74 
Congestion  of  meninges  in  epil- 
epsy, 313 
of  pia  in  epilepsy,  315 
of  skull  in  epilepsy,  313 
Conjunctival    hemorrhagic    ex- 
travasations after  con- 
vulsion, 269 
during  convulsion,  250 
Consanguinity,  epilepsy  and,  72 


Constipation  in  etiology  of  epi- 
lepsy, 113 
Control  of  patient,   337 
Controlling  center,  locating  of, 

424 
Convulsions,  blood  after,  270 
blood  in,  toxicity  of,  328 
body-temperature  after,  260 
burns  during,   250 
cases       without,       prior       to 

twentieth  year,   32 
chromatolysis  folloAving,  326 
circulation  after,  271 
diagnosis  of,  type  of,  33 
dislocations  during,  24S 
effects  on  eye,  268 
elements  of  cortex  involved, 

325  ,     .      , 

exhaustion-paralysis  after,  252 

diagnosis,   254 
experimental,    on    lower    ani- 
mals,  309 
fractures  during,   248 
gastric    contents   in,   toxicity 

of,  328 
glossitis  after,   248 
hemorrhagic      extravasations 

during,  250 
keeping  records  of,  45 
lead,    epilepsy   and,    differen- 
tiation, 285 
leukocytic  invasion  of  cortex 

in,  326 
occasional,  therapeutic  value, 

361 
origin  of,   321,  322 

theories,   321 
pyramidal  tracts  and,   323 
role  of  motor  elements  in,  323 
role   of   sensory   elements   in, 

323,  330 
saturnine,   epilepsy   and,   dif- 
ferentiation,  285 
scalp  scars  after,  24S 
sequelae,  247 

blood,  270 

body-temperature.   260 

burns,   250 

circulation,   271 

dislocations,   248 

exhaustion-paralysis,  252 

eye,  268 

fractures,  248 

glossitis,   248 

hemorrhagic         extravasa- 
tions,   250 

scalp  scars,  248 

sudden  blindness.   269 

tongue  scars,  247 
simulation,   286 


INDEX. 


5°9 


Convulsions,  starting  point  of, 

324 
sudden  blindness  after,   269 
sweat  in,  toxicity  of,  328 
tetanic,   epilepsy   and,   differ- 
entiation,  286 
tongue  scars  after,  247 
toxemic,  epilepsy  and,  differ- 
entiation, 284 
tracts  transmitting,  323 
uremic,  epilepsy  and,  differen- 
tiation, 285 
urine  in,  toxicity  of,  328 
Cornu  ammonis,  sclerosis  of,  in 

epilepsy,  319 
Cortex  of  brain,  bromid  locally, 
effect,  324 
cell  changes  in,  62,  321,  325 
cocainization  of,  effect,  324 
electric  irritability  of,  310 
elements    of,    involved    in 

fit,  325 
faradization    of,    to    locate 

controlling  center,  424 
leukocytic    invasion    of,   in 

epilepsy,  326 
pathologic     lesions    of,     in 

epilepsy,  325 
scars  of,  removal,  423 
Cortical  cells,  action  of  bromids 
on, 330 
elements,      sensory,      clinical 

importance,  331 
epilepsy,  definition,   25 
gliosis,  convulsions  and,  321, 

322 
origin    of    epileptic    fit,    321, 
322 
Counter-irritation  in  treatment, 

402 
Cranium,   traumatic   lesions   of, 

epilepsy  from,  101 
Criminal      acts,      premeditated, 

in  epilepsy,  497 
Cry,  epileptic,   147 
Cure,  definition,   293 

under  treatment,  290 
Cyst  of  brain  in  epilepsy,  319 
removal,  423 


Danger  to  life  in  epilepsy,  304 
Deafness  as  aura,  230 
Death,  average  age  at,  308 

causes,  305 

danger  of,  304 

from   bromid   poisoning,    364 

sudden,  306 
Definition  of  epilepsy,   14 


Degeneration,    stigmata   of,    42 

classification,  43-45 
Delusions  in  epilepsy,  467 
Dementia,    epileptic,    40,    332, 

455 

Dental    caries    in    etiology    of 
epilepsy,   no 

Dentition    in    etiology    of    epi- 
lepsy, 78,  in 

Developmental    epilepsy,    cases 
embraced,  31 

Diabetes,  effect  on  epilepsy,  388 

Diagnosis,   274 
differential,   274 
division     of      cerebronervous 
system  in,   105 

Diaphragm,    spasm   of,    as   epi- 
leptic equivalent,   179 

Diet  of  epileptics,   353 

Differential  diagnosis,   274 

Dinner  menu  for  epileptics,  356 

Diphtheria,    effect   on   epilepsv, 
388 
in  etiology  of  epilepsy,  90 

Diplegia,  cerebral,  in    epilepsy, 
316 
infantile  cerebral,  lesions  of, 
in  epilepsy,  316 

Diplopia  as  aura,  227 

Dislocations  during  convulsions, 
248 

Dissimilar   hereditary  epilepsy, 
cases  embraced,  30 
etiology,  61 
heredity  in  etiology,  61 
■    proportion  of  cases  due  to, 

67 
Diurnal  epilepsy,  definition,  25 

Dreamy  state,  epileptic,   157 
Drugs  in  epilepsy,  362 
Dura  mater,   adhesions  to,   re- 
moval of,  422 

changes  in,   314 

degeneration  of,  calcareous, 

3i4 
false     hemorrhagic     mem- 
brane on,   314 
lesions  of,  in  epilepsy,  314 
Dyspepsia   in    etiology    of    epi- 
lepsy, 113 


Edema  of  pia,  315 

Education   of   children,    349 
of  colonists,  340,  342,  345 
of  patient,   340,   342,   345 
Sloyd  system,  348 

Electric    irritability    of    cortex, 
310 


5i° 


INDEX 


Electricity,  385 

shock    from,    in    etiology    of 
epilepsy,   124 

Embolism  in  epilepsy,  321 

Emergency  prescription  for  sta- 
tus, 208, 210 

Emotional    shock    in    etiology 
of  epilepsy,   91 

Emotionalism,    paradoxical    re- 
ligious,   medicolegal    aspects, 

473  .,       . 

Enteralgia  as  epileptic  equiva- 
lent,  180 
Epidemic  epilepsy,   97 
Epigastric  aura,   232 
flatulence  in,   233 
indigestion  in,   233 
statistics,   234 
Epilepsia,   13 
Epilepsie,   13 

larvee,  definition,   26 
parcellaire,   181 
partielle,   181 
Epilepsin  fallendsot,   13 
Epilepsy,  abdominal  section  for, 
426.       See  also  Abdominal 
section 
abortive,   definition,   25 
accidental,     after      twentieth 
year,  cases  embraced,  32 
cases  embraced,   31 
acute,  195.       See  also  Status 

epilepticus 
acute  infantile,  definition,  25 
age  of  occurrence,  48 

influence  of  heredity  on, 

alcoholic,  definition,  25 
alcoholism    and,     differentia- 
tion,  279,   285 
auditory,  definition,   25 
auricular,   operation  for,   402 
concurrent   disease   and,    386 
cortex,  changes  in,  62,  321 
cortical,   definition,   25 
definition,   14 
of  word,   11 
developmental,      cases      em- 
braced, 31 
diagnosis,   274 
diurnal,   definition,    25 
due    to    injury,    medicolegal 

aspects,  499 
effect  on  mind,  43 8 
epidemic,  97 

etiology,  58.     See     also   Eti- 
ology 
examination    for,    33.  See 

also  Examination 
exciting  agents,  328 


Epilepsy,  experimental,    patho- 
logic value,  309 

eye-strain  in,  relief  of,  388 

frequency  of,  46 
seizures,   193 

from     accident,     medicolegal 
aspects,  499 

gastric,   definition,   25 

general  paralysis  and,  differ- 
entiation,  280 

genius  and,  464 

habit,   17,   303 

lesions  producing,  41 

hemiplegic,   181 
definition,   25 

hereditary,    dissimilar,    cases 
embraced,  30 
etiology,   61 
similar,  cases  embraced,  30 
etiology,   61 

hysterectomy    for,    with    re- 
moval of  ovaries  and  tubes, 

433  .     . 

hysteria  and,   differentiation, 

276 
hysteric,  definition,   25 
idiocy  from,  453 
idiopathic.  See   Idiopathic 

epilepsy 
infantile  accidental,  cases  em- 
braced, 31 

idiopathic,  cases  embraced, 
31 

inherited,  cases  embraced, 

3° 
etiology,  61 
traumatic,  cases  embraced, 

31 
insanity    and,    similarity,    23 
intestinal,   definition,   25 
Jacksonian,    181.        See    also 

Jacksonian  epilepsy 
larvated,  definition,   26 
lead  convulsions   and,   differ- 
entiation,  285 
leukomain      poisoning      and, 

329 

life  insurance  and,   500 
longevity  and,   307 
maniacal,   definition,   26 
masked,  definition,   26 
matutinal,   definition,   26 
medicolegal  aspects,  471 
Meniere's  disease   and,  differ- 
entiation, 285 
mental,  definition,   26 
states  due  to,  438 
myoclonus,    190.         See   also 

Myoclonus  epilepsy 
nocturnal,   definition,   26 


INDEX. 


511 


Epilepsy,    occupation    and,    in- 
fluence of,  56 

organic,  etiology,  400 
operating  for,  400 

origin  of  fit,  321 

parcellar,   160,   181 

partial,    181.     See  also  Jack- 
sonian  epilepsy 

polioencephalitis,   317 

procursive,   240 

prognosis   of,    290.      See   also 
Prognosis 

psychic.         See   Psychic   epi- 
lepsy 

psychologic  aspects  of,  438 

race  and,  55 

reflex,  165.       See  also  Reflex 
epilepsy 

retinal,   251,   269 

salpingo-oophorectomy       for, 

434 

saturnine ,   114 

saturnine     convulsions     and, 
differentiation,   285 

secondary,   167 

seizure  types,   139 

senile,  cases  embraced,  32 

serial,   161.       See  also  Serial 
attacks 

sex  and,  frequency  ratio,  52 

silent  forms,   16 

simulation  of,  detecting,  286 

spinal,   122 
definition,   26 
provoked,    definition,    26 

status    epilepticus    following, 
196 

symptomatic,  definition,  26 

syncope   and,    differentiation, 
2S3 

synonyms,    11 
,  syphilis  and,   318 

syphilitic,  definition,  26 

tetanic  convulsions  and,  dif- 
ferentiation,  286 

tetanoid,  186.     See  also  Teta- 
noid epilepsy 

thalamic,  definition,   26 

theories  of,  early,   310 

thrombosis  and,  317 

time  of  seizures,   193 

toxemic  convulsions  and,  dif- 
ferentiation, 284 

toxic,  cases  embraced,  32 

traumatic,      after     twentieth 
year,  cases  embraced,  32 
cases  embraced,  31 
definition,   26 

treatment,  surgical,  393.     See 
also  Treatment,  surgical 


Epilepsy,    trephining   for.     See 
Trephining 
types  inoperable,  393 
uremic   convulsions  and,   dif- 
ferentiation, 285 
uterus  and,  427 
varieties        occurring       after 
twentieth  year,  32 
common      from     birth      to 
third  year,  30 
from     fourth     to    twen- 
tieth  year,  31 
non-convulsive,     prior      to 
twentieth  year,  32 
vasomotor,  definition,   26 
vertigo    and,    differentiation, 
285 
Epileptic  amaurosis,  269 

aura,  forms  of,  221.     See  also 

Aura,  epileptic 
automatism,  442 

medicolegal    aspects,     444, 

497 
mental  state  in,  439 

convulsions,  sequela?,  247. 
See  also  Convulsions,  se- 
quela 

cry,   147 

dementia,  40,  455 

dreamy  state,   157 

equivalents,   169 

angina  pectoris  as,  177 
asthmatic  affections  as,  178 
definition,    169 
diaphragmatic     spasm     as, 

179 
enteralgia  as,   180 
gastralgia  as,   180 
glottic  spasm  as,  178 
hunger  as,  180 
laryngismus    stridulus     as, 

x?8  ,     , 

laughter    unprovoked      as, 

178 
migraines  as,   180 
nausea  as,   180 
nocturnal     pollutions      as, 

178 
paroxysmal  tachycardia  as, 

177 
pertussis  as,   179 
psychic,    170 

case  illustrating,   173 

with  motor  disorders,  171 
sleep  states  as,  178 
vomiting  as,   180 
whooping-cough  as,    179 
idiocy,  40,  453 
mania,  440 

chloral  hydrate  in,  377 


512 


INDEX. 


Epileptics,  testamentary  capac- 
ity of,  501 
Epileptiform  cases,   16 
Epileptoid  cases,   16 
Equivalents,  epileptic,  169.   See 

also  Epileptic  equivalents 
Ergotin,    Bonjeon's,   in     status, 

213 
Erysipelas,  effect  on  epilepsy,  387 
Etat   de   mal,    195.         See    also 

Status  epilepticus 
Ether  in  status,   213 
Etiology,   58 

acetone  in,   329 

alcoholism  as  hereditary  fac- 
tor, 67 

anxiety  in,   99 

asphyxia  in,    133 

bee  stinging  in,   134 

buccal    cavity    disorders    in, 
no 

central    nervous    system    in, 
focal  lesions  of,   133 

cerebral  hemorrhages  in,   75 
palsies  in,   74 
traumatic  lesions  in,  10 1 

classification,    23.        See   also 
Classification 

cocain  in,   136 

congenital   factors  in,   defini- 
tion,  74 

consanguinity  as  factor  in,  72 

constipation  in,   113 

dentition  in,  78,  in 

diphtheria  in,   90 

dyspepsia  in,    113 

exciting  causes,   58 

eye-strain  in,   136 

factors  in,  in  earlier  years,  73 

fatigue  in,   133 

foods  in,   113 

fright  in,   91 

gastro-intestinal  disorders  in, 
no 

grief  in,   99 

heart  disease  in,   125 

hereditary  factors,  definition, 

74 
heredity  in,   59,   61,   333 
dissimilar,   6 1 
alcohol  in,  67 
insanity  in,   68 
tuberculosis  in,  69 
similar,  61 
hydrocephalus  in,   132 
hypertrophy  of  brain  in,   131 
of   Schneiderian  membrane 

in,   135 
inciting  agents,   328 
indigestion  in,    111 


Etiology,  infectious  fevers  in,  82 

influenza  in,   89 

insanity  as  hereditary  factor, 
68 

lead  poisoning  in,   114 

leukomain  poisoning  in,  329 

malaria  in,   89 

masturbation  in,   121 

maternity  in,    118 

measles  in,   90 

meningitis  in,   91 

menopause  in,   118 

menstrual  disorders  in,  116 

nasal  growths  in,   135 

nephritis  in,  scarlatinous,   83 

nutrition  in,   in 

overwork  in,   99 

pertussis  in,   85 

phimosis  in,    134 

pneumonia  in,   89 

predisposing  causes,   58 
of  early  life,   61 

pregnancy  in,   118 

renal  disease  in,   115 

scarlet  fever  in,   82 

shock  from  electricity  in,  124 
emotional,   91 

sleep  in,   130 

spinal  lesions  in,    104 

sporadic  causes,   131 

stomach  trouble  in,  in 

stricture  of  urethra  in,  134 

syphilis  in,    72,    121 

thermic  fever  in,   87 

tobacco  in,   114 

trauma  in,   10 1 

tuberculosis  as  hereditary  fac- 
tor, 69 

typhoid  fever  in,   8S 

typhus  fever  in,   89 

vaccination  in,   134 

whooping-cough  in,  85 

worms  in,   135 

yellow  fever  in,   89 
Examination,  family  history  in, 

33 
history  of  case  m,  36 
method  of,   33 
of  heart,  41 
of  lungs,  41 
of  memory,  40 
of  mental  condition,  39 
of  patient,   38 
of  physiognomy,  38 
of  reproductive  organs,  42 
personal  history  in,   34 
physical,  40 
scheme  outlined,   t>3 
stigmata  of  degeneration  in ,  42 
thermometer  in,  42 


INDEX. 


513 


Exciting  causes  of  epilepsy,  58 

Exhaustion-paralysis  after  con- 
vulsions, 252 
diagnosis,  254 
hemorrhages  and,  320 
in  epilepsy,  332 

Experimental    epilepsy,    patho- 
logic value,  309 

Extravasations,       hemorrhagic, 
during  convulsions,  250 

Eye,  effects  of  convulsions  on, 
268 

Eye-strain  in  etiology,   136 
relief  of,  388 


Facial  asymmetries  in  epilepsy, 

3*3         t       . 
Facies  epileptica,  275 

in  diagnosis,   38 
Fallopian    tubes    and    ovaries, 

removal  of,  in  hysterectomy, 

433 
Fallsucht,   13 
Family  history  in  examination, 

33 
of  patient,  33 
Faradization  of  cortex  to  locate 

controlling  center,  424 
Fatigue,    extreme,    in    etiology 

of  epilepsy,  133 
Fear  in  psychic  aura,  238 
Feeble-mindedness  in  epilepsy, 

45i 
Fere's  classification  of  epileptic 

aura,  225 
Fissure  of  Rolando,  location  of, 
418 

of  Sylvius,  location  of,  418 
Fit,   13 

origin  of,   321 
Flat-headedness,  43 
Flatulence    in    epigastric    aura, 

233 
Focal  lesions  of  central  nervous 

system  in  etiology,  133 
Folie  circulaire,  440,  460 
Foods  for  epileptics,    355 

in   etiology   of   epilepsy,    113 

not  to  be  eaten,  357 
Fractures    during    convulsions, 
248 

of  skull,  epilepsy  from,  102 
Freedom    and    confinement    in 

Colony,  342 
Frequency  of  epilepsy,  46 

in  each  sex,   52 
Fright  in  etiology  of  epilepsy,  91 
33 


Gastralgia  as  epileptic  equiva- 
lent, 180 
Gastric  contents  in  convulsions, 
hypotoxicity  of,  328 
epilepsy,  definition,  25 
Gastro-intestinal     disorders     in 

etiology  of  epilepsy,  no 
General  treatment,  336 
Generative     organs,     examina- 
tion of,  42 
Genius,  epilepsy  and,  464 
Gliomata  of  brain   in   epilepsy, 

320 
Gliosis,  cortical  convulsion  and, 

321,  322 
Glossitis     after    injury     during 

convulsion ,  248 
Glottis,   spasm  of,   as   epileptic 

equivalent,   178 
Gluttony  as  diagnostic,  41 
God-making  disease,   13 
Gold     foil     after     removal     of 

growth  from  brain,  425 
Gowers'  classification  of  epilep- 
tic aura,  224 
Grand  mal,   13 
definition,   19 
body-temperature   in,   263, 

264, 267 
bromid  in,  367 
clinical  picture,  146 
cry  in,   147 
falling  in,   146 
frequency,   139 
illustrative  cases,   141 
place  of  initial  movement, 

146 
status   epilepticus  in,    196, 

197 
traumatic,     operating    for, 

394 

Grief  in  etiology  of  epilepsy,  99 

Grippe  in  etiology  of  epilepsy, 
89 

Gross  pathology,  311 

Gunshot  wounds  of  brain,  epi- 
lepsy from,  102 


Habit  epilepsy,  17,  303 

lesions  producing,  41 
Hallucinations    of   sight   during 

attacks,   185 
Haut  mal,   13 

Heart    disease    in    etiology    of 
epilepsy,   125 
death  from,  305 
examination  of,  41 


5i4 


INDEX. 


Hemiplegia,    cerebral,     in    epi- 
lepsy, 316 
infantile    cerebral,  lesions  of, 
in  epilepsy,  316 
Hemiplegic  epilepsy,   181 

definition,   25 
Hemorrhage,   cerebral,   as  etio- 
logic  factor,  75,  321 
from  trauma,  epilepsy  from, 
102 
in  removing  controlling  cen- 
ter, 424 
in  status  epilepticus,  320 
Hemorrhagic         extravasations 
during  convulsions,  250 
membrane,  false,  on  dura    in 

epilepsy,  314 
pachymeningitis   in   epilepsy, 
315 
Hereditary  causes,  definition,  74 
influence     of,     on     age     of 
occurrence,   71 
epilepsy,  dissimilar,  cases  em- 
braced, 30 
etiology,  61 
similar,  cases  embraced,  30 
etiology,   61 
syphilis  as  etiologic  factor,  72 
Heredity  as  etiologic  factor,  59, 
61 
dissimilar,  as  etiologic  factor, 
61 
proportion  of  cases  due 
to,  67 
in  etiology,  333 
influence  of,  on  age  of  occur- 
rence, 51,  71 
similar,  as  etiologic  factor,  61 
proportion  of  cases  due 
to,  64 
Highest-level    division    of    ner- 
vous system,  105,  106 
History,    family,    in    examina- 
tion, 33 
of  patient,  33 
of  case,  36 

of  patient  himself,   34 
Home  treatment,   338 
Hunger  as  epileptic  equivalent, 

180 
Hydrocephalus,      contours      of 
skull  in,  43 
in  etiology  of  epilepsy,  132 
Hydrotherapy,   385 
Hyperplasia,  neuroglia,   in   epi- 
lepsy,  327 
Hypertrophy  of  brain  in  etiol- 
ogy of  epilepsy,  131 
of  Schneiderian  membrane  in 
etiology,   135 


Hypochlorization     method      of 

treatment,  370 
Hypodermic   injections  of   bro- 

mids  in  status,  211 
Hysterectomy  with  removal  of 

ovaries  and  tubes,  433 
Hysteria,  epilepsy  and,  differen- 
tiation, 276 

movements  in,  279 
Hysteric  epilepsy,  definition,  25 


Ice  in  status,  210,  211 
Idiocy,  epileptic,  40,  453 
Idiopathic  epilepsy  after  twen- 
tieth    year,     cases     em- 
braced,  32 
cases  embraced,  32 
definition,   25 
exhaustion-paralysis    after, 

253. 
infantile,    cases    embraced, 

3i 
prognosis,   292 
trephining  in,  399 
Ill-humor  in  epilepsy,  440,  449 

medicolegal  aspects,  474 
Imagination  in  epilepsy,  237 
Imbecility  from  epilepsy,  451 
Impulsiveness  in  epileptics,  496 
Indigestion   in   epigastric   aura, 
233 
in  etiology  of  epilepsy,  111 
Indoor  occupations,   351 
Infantile       cerebral        diplegia, 
lesions    of,    in    epilepsy, 
316 
hemiplegia,    lesions    of,    in 

epilepsy,  316 
palsy,  meninges  in,  314 
nature  of  lesion,  317 
syphilis     in,     congenital, 

318 
epilepsy,      accidental,     cases 
embraced,  31 
acute,  definition,   25 
idiopathic,  cases  embraced, 

inherited,    cases  embraced, 

3° 
Jacksonian,   184 

traumatic,  cases  embraced, 

31 
syphilis   in    etiology   of    epi- 
lepsy,  124 
Infectious  fevers   as  factors  in 

etiology,  82 
Influenza  in  etiology  of  epilepsy, 


INDEX. 


515 


Inherited      epilepsy,     infantile, 
cases  embraced,  30 
etiology,  61 
Injury,  epilepsy  due  to,  medico- 
legal aspects,  499 
Insanity,  acute  confusional,  440, 

456 
as  hereditary  factor,   68 
circular,  440,  460 
epilepsy  and,  similarity,  23 
paroxysmal  epileptic,  medico- 
legal aspects,  476 
post-paroxysmal        epileptic, 

439.   446 
pre-paroxysmal,  439,  446 
medicolegal  aspects,  471 
Insomnia    after    status,    treat- 
ment, 217 
chloral  hydrate  in,  377 
Instruments  for  trephining,  420 

sterilization  of,  429 
Insurance,  epilepsy  and,  500 
Intermediate  cases,  262 
Inter-paroxysmal  mental  states, 

440  _ 
Intestinal  epilepsy,  definition,  25 
Intoxication,    bromid,    preven- 
tion of,  368,  369 
Invalidism,     discouraging    idea 

of,  345 
Iron,  383 
Irregular  aura,  243 

somnolence  as,  243 
epileptic  aura,  223 
Irritability  in  epilepsy,  440,  449 
of  cortex,  electric,  310 
transitory  periodic,  449 

medicolegal  aspects,  474 
Isolated  attacks,  body-tempera- 
ture in,  268 
body  -  temperature    after, 
261 


Jacksonian  epilepsy,  181 
acromegaly  and,   186 
clinical  picture,   158,   182 
definition,   19,   25,   26 
etiology,   103,   181 
exhaustion-paralysis    after, 

253 
frequency,   140 
from  cerebral  trauma,   103 
from  syphilis,   122 
hallucinations   of   sight   in, 

i85 

illustrative  cases,   158 

infantile,   184 

ophthalmic    migraine    and, 


Jacksonian     epilepsy,    physical 

results,   183 
place  of  initial  movement, 

182 
rabbit's  nose  in,  182 
reflex  epilepsy  and,  168 
status  epilepticus  in,  197 
tetanoid   shocks   replacing, 

184 
uremia  in,   116 
with     tonic     contractions, 

184 
with  vibratory  movements, 

184 


Kidney    disease   in  etiology  of 
epilepsy,  115 


Larvated    epilepsy,  definition, 
26 

Laryngismus  stridulus    as  epi- 
leptic equivalent,   178 

Latin  synonyms  for  epilepsy,  11 

Laudanum,  373 

Laughter,   unprovoked,    as  epi- 
leptic equivalent,  178 

Lead  convulsions,  epilepsy  and, 
differentiation,  285 
poisoning  in  etiology  of  epi- 
lepsy,  114 

Leukocytic   invasion   of   cortex 
in  epilepsy,  326 

Leukomain    poisoning,  epilepsy 
and,  329 

Life,  danger  to,  in  epilepsy,  304 
insurance,    epilepsy  and,  500 

Ligation  in  treatment,  402 

Liquor    arsenicalis    to    prevent 
bromic  acne,  369 
potassii    arsenitis   with    bro- 
mid, 370 
trinitrim  with  bromid,  378 

Longevity,  epilepsy  and,  307 

Lowest-level    division    of    ner- 
vous system,  105 

Lungs,  examination  of,  41 


Macroscopic  pathology,  311 
Malaria,  effect  on  epilepsy,  386, 

387 
in  etiology  of  epilepsy,  89 
Mania,  epileptic,  440,  448 
chloral  hydrate  in,  377 
paroxysmal,  440,  448 
medicolegal  aspects,  476 
transitory  epileptic,   456 
Maniacal  epilepsy,  definition,  26 


5i6 


INDEX. 


Manic-depressive  insanity,  440, 

456 
Manual    education    of    patient, 

34o, 342, 345 
Marriage  in  treatment,  352 

prognosis  and,  302 
Masked  epilepsy,  definition,  26 

status,  305 
Masturbation     in     etiology     of 

epilepsy,   121 
Maternity   in    etiology    of    epi- 
lepsy,  118 
Matutinal    epilepsy,    definition, 

26 
Measles,  effect  on  epilepsy,  387 

in  etiology  of  epilepsy,  90 
Medical  treatment,  359 
Medicolegal  aspects  of  epilepsy, 

471 
Medico-pedagogic        treatment, 

345 
Memory,  examination  of,  40 
in  post-epileptic  automatism, 

497 
loss  of,  in  epilepsy,  440,  450 
Men,  frequency  of  epilepsy  in, 

52 
Meniere's  disease,  epilepsy  and, 

differentiation,  285 

Meninges,  changes  in,  312,  314 

congestion     of,    in     epilepsy, 

313 
in    infantile    cerebral    palsy, 

3J4 
macroscopic  lesions  of,  312 
Meningitis  in   etiology    of    epi- 
lepsy, 91 
Menopause  in    etiology  of   epi- 
lepsy, 118 
Menstruation,    disorders    of,    in 
etiology  of  epilepsy,   116 
onset  of,  prognosis  and,  301 
status  epilepticus  and,   198 
Mental    capacity    in    epilepsy, 
462 
conditions,  age  arid,  relation, 
299 
as  guide  in  prognosis,  297 
examination  of,  439 
frequency  of  attacks   and, 

300 
sex  and,  relation,  299 
epilepsy,  definition,  '26 
reduction  in   epilepsy,   463 
states  due  to  epilepsy,  438 
Menu  for  epileptics,   355 
Microcephalic  contours,  43 
Microscopic  pathology,   321 
Middle  level  division  of  nervous 
system,  105 


Migraines   as  epileptic    equiva- 
lents, 180 

ophthalmic,  Jacksonian    epi- 
lepsy and,   184 
Milk  leg  in  etiology  of  epilepsy, 

120 
Mixed  seizures,  frequency,   140 
Morbus  astralis,   13 

caducus,   12 

commitialis,   11 

convivialis,   12 

dagmoniacus,   13 

Deificus,   13 

fcedus,   12 

Herculeus,   11 

insputatis,   12 

major,   11 

mensalis,   12 

sacer,   1 1 

scelestus,   13 

sideratus,   12 

sonticus,   12 

unicatus,   12 

viridellus,   12 

vitriolatus,   12 
Morphia,  373 

effects  of,  375 
Morphin  in  status,  214 
Motor  aura,  239 
running,   240 
trembling,  242 

elements,   role   of,   in  spasm, 

323. 33° 
epileptic  aura,  223 
My  ocl  onus-epilepsy,   190 
clinical  picture,   190 
diagnosis,   191 
etiology,   191 
pathology,   192 
prognosis,   192 


Narcotics  in  status,  213 
Nausea  as  epileptic  equivalent, 

180 
Negroes,  epilepsy  among,  56 
Nephritis,  scarlatinous,  in  etiol- 
ogy of  epilepsy,  83 
Nervous  system,  effect  of  potas- 
sium bromid  on,  363 
central,  focal  lesions  of,  in 

etiology,  133 
division    of,    as    diagnostic 
aid,  105 
Neuroglia    hyperplasia    in   epi- 
lepsy, 327 
phagocytic  function  of,  327 
Nicotin  in  etiology  of  epilepsy, 

114 
Nitrate  of  amyl  in  status,  212 


INDEX. 


517 


Nitroglycerin,   378 
Nocturnal    epilepsv,    definition, 
26 

pollutions  as  epileptic  equiva- 
lent, 178 
Nodding  spasms,   189,   190 
Nomenclature  of  forms,  25 
Nose,  growths    in,    in    etiology 

of  epilepsy,  135 
Nothnagel's  classification,  28 
Nuclear     changes     in     cortical 

cells,  325 
Nursing  status  case,  217 
Nutrition,  effect  of  bromid  on, 

364 
in  etiology  of  epilepsy,  in 
Nutritional  disturbances  in  epi- 
lepsy, 41 


Occupation,  bearings    on   epi- 
lepsy, 56 
Oil  of  sesame  in  status,  214 
Operation,        clinico-pathologic 
guides  to,   395 
peripheral,  401 
point  of,  398 
time  for,  399,  404 
types  suitable,  393 
Opium-bromid  treatment,  373 
Optical  illusions  in  epilepsy,  226 
Organic  epilepsy,   etiology,  400 
from  uremia,  116 
operation  for,  400 
Osteosclerosis   of   skull    in   epi- 
lepsy, 312 
Outdoor  life  in  treatment,  351 
Ovaries    and    tubes,    hysterec- 
tomy with  removal  of,  433 
removal  of,  for  epilepsy,  426 
Overwork  in    etiology    of     epi- 
lepsy, 99 
Oxycephalus,  43 
Oxygen  in  status,  214 


Pachymeningitis,      hemorrha- 
gic, in  epilepsy,  315 
Paradoxical  religious  emotional- 
ism, medicolegal  aspects,  473 
Paralysis,  cerebral,  as   etiologic 
factor,  74 
exhaustion-,  after  convulsion, 
252 
diagnosis,  254 
hemorrhages  and,  320 
in  epilepsy,  332 
general,  epilepsy  and,  differ- 
entiation, 280 
in  epileptics,  40 


Paralysis,      infantile      cerebral, 
meninges  in,  314 
nature  of  lesion,  317 
syphilis  in,  congenital,  3 18 
of   respiratory   center,    death 
from,  307 
Parcellar  epilepsy,   160,   181 
Paroxysmal  mania,  440,  448 
medicolegal  aspects,  476 
mental  states  due  to  epilepsy, 

439 
Partial  epilepsy,  181.      See  also 

Jacksonian  epilepsy 
Passio  caduca  et  perdito,  13 
Pathogenesis,  328 

predisposition,   328 
Pathology,   309 

clinical   view   of  newer   find- 
ings, 329 
conclusions,  328 

from    present    knowledge, 

333 
gross,  311 
history,   309 
macroscopic,  311 
microscopic,  321 
Patient,  control  of,   337 

education  of,   340,   342,  345 

Sloyd  system,  348 
home  treatment  of,  33S 
self-control  of,  value,  339 
treatment  of,  336 
Pedagogic  treatment,  345 
Pepto-mangan,  384 
Peripheral  operations,  401 
nerves,     injury    to,    epileptic 
aura  and,  222 
Personal    history    in    examina- 
tion, 34 
Pertussis    as    epileptic    equiva- 
lent, 179 
in  etiology  of  epilepsy,  85 
Petechial    eruption    after    con- 
vulsion, 252 
Petit  mal  seizure,  13 

body-temperature         in, 

264, 265, 267 
clinical  picture,   147 
definition,   19 
frequency,   139 
illustrative  cases,   147 
psychic  seizure  and,  dif- 
ferentiation,  21 
Phagocytic  function  of  neurog- 
lia in  epilepsy,  327 
Phenacetin,  384 
Phimosis  in  etiology  of  epilepsy, 

x34 
Phlegmasia  alba  dolens  in  etiol- 
ogy of  epilepsy,  120 


INDEX. 


Physical  examination  of  patient, 

40 
Physiognomy,    examination    of, 

38 

Physiologic  stigmata  of  degen- 
eration, 44 
Pia  mater,  changes  in,  315 

congestion  of,  in   epilepsy, 

315 
edema  of,   315 
lesions  of,  in  epilepsy,  314, 

3i5 
opacity  of,  315,  316 
thickening  of,  315,  316 
Pneumonia  in  etiology   of   epi- 
lepsy, 89 
Polioencephalitis,  epilepsy  and, 

3i7 

Pollutions,  nocturnal,  as  epilep- 
tic equivalents,  178 

Polypi,    nasal,    in    etiology    of 
epilepsy,  135 

Post-epileptic  automatism, 

medicolegal  aspects,  497 

Post -paroxysmal     epileptic     in- 
sanity, 439, 446 
mental  disturbances,  439,  446 

Potassium    bromid,     effect     on 
nervous  system,  363 
prognosis  and,  292 

Practical  classification,   30 

Predisposing  causes  of  epilepsy, 
58 
in  early  life,  61 

Predisposition  to  epilepsy,   328 

Pregnancy   in    etiology  of    epi- 
lepsy,  118 

Premeditated  criminal  acts,  497 

Pre-natal  causes,  definition,  74 

Pre-paroxysmal    insanity,    439, 
446 
medicolegal  aspects,  471 
mental  disturbances,  439,  446 

Priestly  disease,   13 

Procursive  epilepsy,  240 

Prognosis,   290 
age  and,  298 
aura,  value  of,  303 
bromids  and,  291 
catamenia  and,  301 
character  of  attacks  and,  300 
frequency  of  attacks  and,  300 
marriage  and,   302 
menstrual'  onset  and,  301 
mental    condition    as    guide, 

297 
potassium  bromid  and,  292 
sex  and,  298 
time  of  attacks  and,  300 

Prophylaxis  of  attack,  359 


Provoked  spinal  epilepsy,  defi- 
nition, 26 
Psychic  aura,  237 
fear,  238 
imagination,  237 
epilepsy,  441 

amyl  nitrate  in,   212 
body-temperature    in,  264, 

267 
bromid  in,  366 
clinical  picture,    152 
definition,   19,   26 
dreamy  state,   157 
frequency,   140 
illustrative  cases,   152 
mental  state  in,  439 
petit  mal  and,  differentia- 
tion, 21 
status  epilepticus  in,  196 
epileptic  aura,  223 
equivalent,   170 

case  illustrating,   173 
with  motor  disorders,  171 
stigmata  of  degeneration,  45 
Psychologic  aspects  of  epilepsy, 

438 
Psycho- visual  aura,  228 
Pulmonary  tuberculosis,    death 

from,  305 
Pulse  after  convulsion,  271 
Punctiform     hemorrhage     after 

convulsions,  250 
Pupils,  dilatation  of,  after  con- 
vulsion, 268 
Pyramidal    tracts,    convulsions 
and,  323 


Rabbit's    nose    in    Jacksonian 

epilepsy,   182 
Race,  influence  on  epilepsy,  55 
Records     of     seizures,     keeping 

of,  45 
Recovery,  definition,   293 
spontaneous,  303 
under  treatment,  290 
Reflex  epilepsy,   165 
definition,   26 
etiology,   165 
illustrative  cases,   165 
Jacksonian    epilepsy    and, 
168 
Religious    emotionalism,    para- 
doxical, medicolegal  aspects, 

473 
Renal    disease    in    etiology    of 

epilepsy,  115 
Reproductive  organs,  examina- 
tion of,  42 


INDEX. 


519 


Respiration,    effect    of    bromid 
on,  364 

in  epilepsy,   232 
Respiratory     center,     paralysis 

of,  death  from,  307 
Retinal  epilepsy,  251,  269 
Rolando's    fissure,    location    of, 

418 
Running  as  motor  aura,  240 


Salpingo-oophorectomy       for 
epilepsy,  434 

Salutatory-  spasms,  189,  190 

Sarcomata  of  brain  in  epilepsy, 
320 

Saturnine  convulsions,  epilepsy 
and,  differentiation,  285 
epilepsy,   114 

Scalp,  preparation    of,  for  tre- 
phining, 416 
scars  from  convulsions,  248 

Scarlatinous  nephritis  in  etiol- 
ogy of  epilepsy,  83 

Scarlet     fever     in     etiology     of 
epilepsy,  82 

Scars  on  brain,  removal,  423 

Schneiderian  membrane,  hyper- 
trophy of,  in  etiology,  135 

Sclerosis  of  cornu  ammonis  in 
epilepsy,  319 

Secondary  epilepsy,   167 

Seizure  types  of  epilepsy,  139 

Seizures,  frequency  of,   193 
time  of,   193 

Self-control,    teaching    patient, 

339 

Seminal   emissions   as   epileptic 

equivalents,  178 
Senile  epilepsy,  cases  embraced, 
32 
nitroglycerin  with,  378 
Sensory  character  of  phenomena 
of  epilepsy,  330 
cortical  elements,  clinical  im- 
portance, 330 
role  of,  in  spasm,  323,  330 
epileptic  aura,  223,  225 
Sequelae    of    convulsions,     247. 
See   also  Convulsions,  sequela 
Serial  attacks,   161 

body-temperature        after, 

261 
bodv-temperature   in,    266, 

268 
frequency,   162 
illustrative  cases,   163 
Serum  treatment,  386 
Sesame  oil  in  status,  214 


Sex,   frequency  of    epilepsy  in 
each,  52 
mental    condition    and,    rela- 
tion, 299 
prognosis  and,   298 
status  epilepticus  and,  197 
Shock,    electric,    in   etiology   of 
epilepsy,   124 
emotional,  in  etiology  of  epi- 
lepsy,  91 
Silent  forms  of  epilepsy,  16 
Similar    heredity     as     etiologic 
factor,  61 
proportion  of  cases  due 
to,  64 
hereditary  epilepsy,  cases  em- 
braced, 30 
etiology,  61 
Simulation     of     epileptic     con- 
vulsions, 286 
Simulo,  381 

Skin,  effect  of  bromid  on,  365 
Skull,  changes    in,  in    epilepsy, 
312 
congestion  of,  in  epilepsy,  313 
deformities  of,  313 
density  of,  in  epilepsy,  312 
injuries,  epilepsy  and,  315 
inner    tables    of,     depression 

of,  315 
macroscopic  lesions  of,  312 
osteosclerosis  of,   312 
steeple-shaped,  43 
traumatic  lesions  of,  epilepsy 
from,   10 1 
Sleep    in    etiology    of    epilepsy, 
130 
states  as  epileptic  equivalents, 
178 
Sloyd  system  of  education,  348 
Smell,    sense    of,    in    epileptics, 
230 
location  of,   231 
Smoking,  352 

cigarette,  in  etiology  of  epi- 
lepsy,  114 
Soda  bicarbonate  with  bromids, 

37° 

Sodium  borate,  375 

bromid,  370 
Solanum  carolinense,  380 
Somnolence  as  aura,  243 
Spasmus  nutans,   189,   190 
Spinal    cord,    effect    of   bromid 
on,  364 
lesions    of,    epilepsy    from, 
104 
epilepsy,   122 
definition,   26 
provoked,  definition,  26 


520 


INDEX. 


Spinal  system  division  of  nervous 

system,   105 
Spontaneous  recovery,  303 
Sporadic  causes  of  epilepsv,  131 
Status  epilepticus,  195,  262 
age  and,   198 
ammonia  in,  216 
amyl  hydrate  in,  213 
amyl  nitrate  in,  212 
antispasmodics  in,  210 
asafetida  in,  212 
atropin  in,   212 
belladonna  in,  212 
blood-letting  in,  210 
body-temperature  in,   266 
bromethyl  in,   212 
bromids  in,  211 

in  prophylaxis,   207 
"  subcutaneously ,   211 
camphor  in,  211 
care  of  patient,  217 
cathartics  in,   210,   211 
chloral  hydrate  in,  214,  377 
chloretone  in,   215 
chloroform  in,   210,   213 
clinical  picture,   202 
coma  in,   204 
convulsive  stage,   203 
duration,   205 
treatment ,   210 
death  from,  305 
definition,   25,   195 
diagnosis,   205 
diet  in,   218 
emergency  prescription  for, 

208, 210 
ergotin  in,  213 
ether  in,  213 
etiology,  immediate  cause, 

201 
first   epileptic   attack   and, 

interval  between,  199 
foods  in,   21S 
forms  of  seizure  occurring 

in,  196 
hemorrhages  in,   320 
historic   consideration,    195 
ice  in,   210,   211 
immediate  cause,  201 
in  grand   mal   seizure,  196, 

197 
in  Jacksonian  epilepsy,  197 
in  psychic  seizure,  196 
inception-symptomatology , 

202 
intervals    between    periods 

in  same  case,  201 
menstruation  and,   198 
morphin  in,   214 
mortality,   207 


Status  epilepticus,  narcotics  in, 
213 
nursing  in,   217 
oxygen  in,   214 
post-status    period,     treat- 
ment,  216 
prognosis,   205 
prophylaxis,   207 
seizures  in,  frequency,  204 
sesame  oil  in,   214 
sex  influence,   197 
status  hystericus  and,   198 
stuporous  stage,  204 
treatment,   215 
surgical  treatment,  209 
temperature  in,   262 
treatment,   207 

of  convulsive  stage,   210 
of  stuporous  stage,  215 
surgical,  209 
trephining  for,   209 
venesection  in,   210 
hystericus,   status  epilepticus 

and,   198 
pareticus,   197 
unilateralis ,   197 
prognosis,   206 
Steeple-shaped  skull,  43 
Sterilization      of      instruments, 

sutures,  etc.,  429 
Stigmata  of  degeneration,  42 

classification  of,  43—45 
Stomach  in  epilepsy,  232 

trouble  in  etiology  of  epilepsy, 
in 
Stricture  of  urethra  in  etiology 

of  epilepsy,    134 
Strontium  bromid,   370 
Subcutaneous  hemorrhage  after 
convulsion,  252 
injections  of  bromids  in  sta- 
tus,  211 
Subintrant  attacks,   262 
Sudden  death,  306 
Suffocation   during  attack,   361 
Supper  menu  for  epileptics,  357 
Surgical  treatment,   393.        See 

also  Treatment,  surgical 
Sutures,  sterilization  of,  429 
Sweat     in     convulsions,     hypo- 

toxicity  of,  328 
Sylvius'  fissure,  location  of,  418 
Sympathetic,  cervical,  resection 

of,  in  treatment,  402 
Symptomatic    epilepsy,    defini- 
tion, 26 
Symptomatology,    classification 

based  on,  18 
Syncope,  epilepsy  and,  differen- 
tiation, 283 


INDEX. 


521 


Synonyms,   11 

Syphilis  as  etiologic  factor,  72, 
121 
congenital,   in   infantile  cere- 
bral palsy,  318 
epilepsy  and,   318 
Syphilitic    epilepsy,    definition, 
26 


Taches  rosees  after  convulsion, 

251 
Tachycardia,     paroxysmal,     as 

epileptic  equivalent,   177 
Taste,  sense  of,  in  epileptics,  230 

location  of,   231 
Teeth,    cutting   of,    as   etiologic 

factor,  78 
Temperamental    effect    of    seiz- 
ures, 449 
Temperature  after  convulsions, 
260 
effect  of  bromid  on,  364 
in  epilepsy,  245 
toxins  and,  268 
Testamentary  capacity   of   epi- 
leptics, 501 
Tetanic     convulsions,     epilepsy 

and,  differentiation,  286 
Tetanoid  epilepsy,   186 
clonic  form,   187 
convulsive,   187 
death  in,   188 
definition,    187 
tetanic,  187 
shocks    replacing   Jacksonian 
epilepsy,   184 
Thalamic     epilepsy,     definition, 

26 
Theories,    early,  regarding  epi- 
lepsy, 310 
of  origin  of  fit,   321 
Thermic    fever    in    etiology    of 

epilepsy,  87 
Thermometer    in    examination , 

42 
Thrombosis,  epilepsy  and,  317 
Thymus,  persistent,  in  epilepsy, 

312 
Tissue  waste,  bromid  and,  365 
Tobacco  in  etiology  of  epilepsy, 

114 
Tongue  scars  from  convulsions, 

247 
Toxemic    convulsions,    epilepsy 

and,  differentiation,  284 
Toxic  epilepsy,  cases  embraced, 

Toxins,  body-temperature  and, 
268 


Tracts  transmitting  spasm,  323 
Transitory  epileptic  mania,  456 
periodic  irritability,  449 

medicolegal  aspects,  474 
Trauma  in  etiology  of  epilepsy, 
101 
ratio  of  cases  due  to,  107 
Traumatic  epilepsy  after  twen- 
tieth    year,     cases     em- 
braced, 32 
cases  embraced,   31 
definition,   26 
infantile,    cases    embraced, 

31 
grand  mal,  operating  for,  394 

Treatment,    abdominal    section 

in ,  4  2  6 .    See  also  A  bdominal 

section 

bromids  in,   353,   363 
physiologic  action,  363 

cervical     sympathetic     resec- 
tion in,  402 

Colony,  339 

counter-irritation  in,  402 

drugs  for,  362 

during  attacks,  361 

education  of  patient  in,  340, 
342,  345.  348 

general,  336 

home,  338 

hypochlorization  method,  370 

hysterectomy    with    removal 
of  ovaries  and  tubes  in,  433 

ligation  in,  402 

marriage  in,   352 

medical,  359 

medico-pedagogic,  345 

of  subject,   336 

operations  for,  peripheral,  401 
time  for,  404 

outdoor  life  in,  351 

prophylactic,   359 

recovery  under,  290 
'salpingo-oophorectomy        in, 

434 
serum,  386 
surgical,   393 

clinico-pathologic    guides 

for,  395 
of  grand  mal,   394 
of  idiopathic  cases,  399 
of  organic  epilepsy,  400 
operative  point,  398 
results,  403 
time  for  operation,  399 
types  suitable,  393 
trephining.       See  Trephining 
Trembling  as  motor  aura,  242 
Trephining,    bulging    of     brain 
into  opening  after,  422 


522 


INDEX. 


Trephining,   closure  of    wound, 

425 

drainage  after,  425 

for  status,  209 

in  idiopathic  epilepsy,  399 

instruments  for,  420 

modus  operandi,  420 

point  of,  398,  419 

preparation  of  patient,  416 

seizure  records  after,  412 

technique,  416 
Trional,  382 

Tuberculosis  as  hereditary  fac- 
tor, 69 

pulmonary,  death  from,  305 
Tumor  of  brain  in  epilepsy,  319, 

422 
Types  of  epileptic  seizures,  139 
Typhoid    fever    in    etiology    of 
epilepsy,   88 
influence  on  epilepsy,  387 
Typhus    fever    in    etiology    of 

epilepsy,  89 


Uremia  in  etiology  of  epilepsy, 

116 
Uremic     convulsions,     epilepsy 

and,  differentiation,  285 
Urethan,  380 
Urethra,  stricture  of,  in  etiology 

of  epilepsy,  134 
Urine     in     convulsions,     hypo- 

toxicity  of,  328 
Uterus  as  retention    cyst,  epi- 
lepsy and,  427 

displacements      of,      epilepsy 
and,  427 


VACCiNATioN[in  etiology  of  epi- 
lepsy,  134 

Vagus  nerve  in  epilepsy,  232 

Vascular    lesions    of    brain    in 
epilepsy,  319 

Vasomotor  epilepsy,  definition, 
26 

Venesection  in  status,  210 

Vertebral    arteries,    ligation  of, 
in  treatment,  402 

Vertiginous  epilepsy,  chloroform 
in,  385 
operations  for,  402 

Vertigo,  epilepsy  and,  differen- 
tiation, 285 

Vision,  double,  as  aura,  227 

Visual  aura,  225 
forms  of,  226 
psycho-,  228 

Voisin's  classification  of  epilep- 
tic aura,  225 

Vomiting    as    epileptic    equiva- 
lent, 180 

Whistling  as  aura,  229 
Whooping-cough     as     epileptic 
equivalent,   179 

in  etiology  of  epilepsy,  85 
Women,   frequency  of  epilepsy 

in,   S2 
Worms  in  etiology  of  epilepsy, 

135 

Yellow     fever  in    etiology    of 
epilepsy,  89 

Zinc, 379 


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EMBRYOLOGY. 


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colors.     Cloth,  $2.50  net. 

WITH    196   ILLUSTRATIONS,   32   IN   COLORS 

The  fact  of  embryology  having  acquired  in  recent  years  such  great  interest 
in  connection  with  the  teaching  and  with  the  proper  comprehension  of  human 
anatomy,  it  is  of  first  importance  to  the  student  of  medicine  that  a  concise  and 
yet  sufficiently  full  text-book  upon  the  subject  be  available.  In  its  first  edition 
this  work  met  this  want  most  admirably,  and  in  its  present  form  it  will  prove  even 
more  valuable.  The  work  has  been  thoroughly  revised,  and  such  additions  have 
been  made  as  the  progress  of  the  science  has  rendered  necessary.  Moreover,  the 
entire  work  has  been  generally  improved.  The  chapter  treating  of  the  Decidual 
and  the  Placenta  has  been  rewritten,  as  has  also  the  greater  part  of  that  upon  the 
Chorion.    In  addition  to  these  changes,  several  new  illustrations  have  been  added. 


PERSONAL  AND   PRESS  OPINIONS 


G.  Carl  Huber,  M.  D., 

Professor  of  Histology  and  Embryology ,  University  of  Michigan,  Ann  Arbor. 

"  I  find  the  second  edition  of  'A  Text-Book  of  Embryology'  by  Dr.  Heisler  an  improve- 
ment on  the  first.  The  figures  added  increase  greatly  the  value  of  the  work.  I  am  again 
recommending  it  to  our  students." 

William  Wathen,  M.  D., 

Professor  of  Obstetrics,  Abdominal  Surgery,  and  Gynecology,  and  Dean,  Kentucky  School  of 

Medicine,  Louisville,  Ky. 
"  It  is  systematic,  scientific,  full  of  simplicity,  and  just  such  a  work  as  a  medical  student 
will  be  able  to  comprehend." 

Birmingham  Medical  Review,  England 

"  We  can  most  confidently  recommend  Dr.  Heisler's  book  to  the  student  of  biology  or 
medicine  for  his  careful  study,  if  his  aim  be  to  acquire  a  sound  and  practical  acquaintance  with 
the  subject  of  embryology." 


SAUNDERS'    BOOKS   ON 


Mallory  and  Wright's 
Pathologic  Technique 

Second  Edition,  Revised  and  Enlarged 


Pathologic  Technique.  A  Practical  Manual  for  Workers  in  Patho- 
logic Histology,  including  Directions  for  the  Performance  of  Autopsies 
and  for  Clinical  Diagnosis  by  Laboratory  Methods.  By  Frank  B. 
Mallory,  M.  D.,  Associate  Professor  of  Pathology,  and  James  H. 
Wright,  M.  D.,  Instructor  in  Pathology,  Harvard  University  Medical 
School.     Octavo  of  432  pages,  with  137  illustrations.     Cloth,  $3.00  net. 

WITH  CHAPTERS  ON  POST-MORTEM  TECHNIQUE  AND  AUTOPSIES 

In  revising  the  book  for  the  new  edition  the  authors  have  kept  in  view  the 
needs  of  the  laboratory  worker,  whether  student,  practitioner,  or  pathologist,  for 
a  practical  manual  of  histologic  and  bacteriologic  methods  in  the  study  of  patho- 
logic material.  Many  parts  have  been  rewritten,  many  new  methods  have  been 
added,  and  the  number  of  illustrations  has  been  considerably  increased.  Among 
the  many  changes  and  additions  may  be  mentioned  the  amplification  of  the  de- 
scription of  the  Parasite  of  Actinomycosis  and  the  insertion  of  descriptions  of  the 
Bacillus  of  Bubonic  Plague,  of  the  Parasite  of  Mycetoma,  and  Wright's  methods 
for  the  cultivation  of  Anaerobic  Bacteria.  There  have  also  been  added  new 
staining  methods  for  elastic  tissue  by  Weigert,  for  bone  by  Schmorl,  and  for  con- 
nective tissue  by  Mallory.  The  new  edition  of  this  valuable  work  keeps  pace 
with  the  great  advances  made  in  pathology,  and  will  continue  to  be  a  most  useful 
laboratory  and  post-mortem  guide,  full  of  practical  information. 


PERSONAL  AND   PRESS  OPINIONS 


Win.  H.  Welch,  M.  D., 

Professor  of  Pathology,  Johns  Hopkins  University,  Baltimore. 

"  I  have  been  looking  forward  to  the  publication  of  this  book,  and  I  am  glad  to  say  that  I 
find  it  a  most  useful  laboratory  and  post-mortem  guide,  full  of  practical  information  and  well 
up  to  date." 

Boston  Medical  and  Surgical  Journal 

"  This  manual,  since  its  first  appearance,  has  been  recognized  as  the  standard  guide  in  patho- 
logical technique,  and  has  become  well-nigh  indispensable  to  the  laboratory  worker." 

Journal  of  the  American  Medical  Association 

"  One  of  the  most  complete  works  on  the  subject,  and  one  which  should  be  in  the  library 
of  every  physician  who  hopes  to  keep  pace  with  the  great  advances  made  in  pathology." 


HISTOLOGY. 


Bohm,  Davidoff,  and 
Huber's  Histology 


A  Text=Book  of  Human  Histology.  Including  Microscopic  Tech- 
nic.  By  Dr.  A.  A.  Bohm  and  Dr.  M.  von  Davidoff,  of  Munich,  and 
G.  Garl  Huber,  M.  D.,  Professor  of  Histology  and  Embryology  in 
the  University  of  Michigan,  Ann  Arbor.  Handsome  octavo  of  503 
pages,  with  351  beautiful  original  illustrations.     Cloth,  $3.50  net. 

INCLUDING   MICROSCOPIC  TECHNIC 

The  work  of  Drs.  Bohm  and  Davidoff  is  well  known  in  the  German  edition, 
and  has  been  considered  one  of  the  most  practically  useful  books  on  the  subject 
of  Human  Histology.  The  excellence  of  the  text  and  illustrations,  attested  by  all 
familiar  with  the  work,  and  the  cordial  reception  which  it  has  received  from  both 
students  and  investigators,  justify  the  belief  that  an  English  translation  will  meet 
with  approval  from  American  and  English  teachers  and  students.  This  American 
edition  has  been-  in  great  part  rewritten  and  very  much  enlarged  by  Dr.  Huber, 
who  has  also  added  over  one  hundred  original  illustrations.  Dr.  Huber's  exten- 
sive additions  have  rendered  the  work  the  most  complete  students'  text-book  on 
Histology  in  existence.  The  book  contains  particularly  full  and  explicit  instructions 
in  the  matter  of  technic,  and  it  will  undoubtedly  prove  of  the  utmost  value  to 
students  and  practical  workers  in  the  Histologic  Laboratory.  Special  attention  is 
called  to  the  fulness  of  the  text,  the  large  amount  of  matter  on  technic,  and  the 
numerous  handsome  illustrations. 


OPINIONS  OF  THE   MEDICAL  PRESS 


British  Medical  Journal 

"  The  combined  authorship  of  so  many  distinguished  men  has  led  to  the  production  of  a  most 
valuable  work.  The  illustrations  are  most  beautiful,  and  beautifully  executed,  and  their  study 
will  be  an  education  in  themselves." 

Boston  Medical  and  Surgical  Journal 

"  Is  unquestionably  a  text-book  of  the  first  rank,  having  been  carefully  written  by  thorough 
masters  of  the  subject,  and  in  certain  directions  it  is  much  superior  to  any  other  histological 
manual." 

American  Medicine 

"  It  is  recognized  as  the  highest  authority  in  Germany.  ...  A  book  on  histology  which 
surpasses  anything  of  its  kind  now  in  print." 


SAUNDERS'    BOOKS    ON 


McFarland's 
Pathogenic  Bacteria 

Fourth  Edition,  Rewritten  and  Enlarged 


A  Text=Book  Upon  the  Pathogenic  Bacteria.  By  Joseph  McFar- 
land,  M.  D.,  Professor  of  Pathology  and  Bacteriology  in  the  Medico- 
Chirurgical  College  of  Philadelphia,  Pathologist  to  the  Medico-Chirur- 
gical  Hospital,  Philadelphia,  etc.  Octavo  volume  of  629  pages,  finely 
illustrated.     Cloth,  $3.50  net. 

JUST  ISSUED 

This  book  gives  a  concise  account  of  the  technical  procedures  necessary  in  the 
study  of  bacteriology,  a  brief  description  of  the  life-history  of  the  important  patho- 
genic bacteria,  and  sufficient  description  of  the  pathologic  lesions  accompanying 
the  micro-organismal  invasions  to  give  an  idea  of  the  origin  of  symptoms  and  the 
causes  of  death.  The  illustrations  are  mainly  reproductions  of  the  best  the  world 
affords,  and  are  beautifully  and  accurately  executed.  Although  but  a  short  time 
has  elapsed  since  the  appearance  of  the  previous  edition,  extensive  progress  has 
been  made  in  the  subjects  of  which  it  treats.  In  this  edition,  therefore,  the  entire 
work  has  been  practically  rewritten,  old  matter  eliminated,  and  much  new  matter 
inserted.  The  chapters  upon  Infection  and  Immunity  have  been  greatly  extended 
by  the  addition  of  the  many  new  facts  recently  added  to  our  knowledge.  The 
value  of  the  work  has  been  considerably  enhanced  by  the  introduction  of  a  large 
number  of  references  to  the  literature. 


PERSONAL  AND   PRESS  OPINIONS 


H.  B.  Anderson,  M.  D., 

Professor  of  Pathology  and  Bacteriology,   Trinity  Medical  College,  Toronto. 
"The  book  is  a  satisfactory  one,  and  I  shall  take  pleasure  in  recommending  it  to  the  students 
of  Trinity  College." 

The  Lancet,  London 

"  It  is  excellently  adapted  for  the  medical  students  and  practitioners  for  whom  it  is  avowedly 
written.  .  .  .  The  descriptions  given  are  accurate  and  readable,  and  the  book  should  prove 
useful  to  those  for  whom  it  is  written." 

New  York  Medical  Journal 

"The  author  has  succeeded  admirably  in  presenting  the  essential  details  of  bacteriological 
technic,  together  with  a  judiciously  chosen  summary  of  our  present  knowledge  of  pathogenic 
bacteria.  .  .  .  The  work,  we  think,  should  have  a  wide  circulation  among  English-speaking 
students  ot  medicine." 


BA  CTERIOLOU  Y  AND  J'A  THOLOG  i '. 


Eyre's 
Bacteriologic  Technique 


The  Elements  of  Bacteriologic  Technique.  A  Laboratory  Guide 
for  the  Medical,  Dental,  and  Technical  Student.  By  J.  W.  H.  Eyre, 
M.  D.,  F.  R.  S.  Edin.,  Bacteriologist  to  Guy's  Hospital,  London,  and 
Lecturer  on  Bacteriology  at  the  Medical  and  Dental  Schools,  etc. 
Octavo  volume  of  375  pages,  with  170  illustrations.      Cloth,  $2.50  net. 

FOR   MEDICAL,  DENTAL,  AND   TECHNICAL   STUDENTS 

This  book  presents,  concisely  yet  clearly,  the  various  methods  at  present  in 
use  for  the  study  of  bacteria,  and  elucidates  such  points  in  their  life-histories  as 
are  debatable  or  still  undetermined.  It  includes  only  those  methods  that  are 
capable  of  giving  satisfactory  results  even  in  the  hands  of  beginners.  The  excel- 
lent and  appropriate  terminology  of  Chester  has  been  adopted  throughout.  The 
illustrations  are  numerous  and  practical,  the  author  considering  that  a  picture,  if 
good,  possesses  a  higher  educational  value  and  conveys  a  more  accurate  impres- 
sion than  a  page  of  print.  The  work  is  not  intended  for  the  medical  and  dental 
student  alone,  having  been  designed  with  the  needs  of  the  technical  student  gen- 
erally constantly  in  view,  whether  he  be  of  brewing,  dairying,  or  agriculture. 

Warren's 

Pathology  and   Therapeutics 

Surgical  Pathology  and  Therapeutics.  By  John  Collins  Warren, 
M.  D.,  LL.D.,  F.  R.  C.  S.  (Hon.),  Professor  of  Surgery,  Harvard  Medical 
School.  Octavo,  873  pages,  136  relief  and  lithographic  illustrations,  33 
in  colors.  With  an  Appendix  on  Scientific  Aids  to  Surgical  Diagnosis 
and  a  series  of  articles  on  Regional  Bacteriology.  Cloth,  $5.00  net; 
Sheep  or  Half  Morocco,  $6.00  net. 

SECOND    EDITION,  WITH   AN   APPENDIX 

In  the  second  edition  of  this  book  all  the  important  changes  have  been  em- 
bodied in  a  new  Appendix.  In  addition  to  an  enumeration  of  the  scientific  aids  to 
surgical  diagnosis  there  is  presented  a  series  of  sections  on  regional  bacteriology, 
in  which  are  given  a  description  of  the  flora  of  the  affected  part,  and  the  general 
principles  of  treating  the  affections  they  produce. 

Roswell   Park,  M.  D., 

In  the  Harvard  Graduate  Magazine . 

"  I  think  it  is  the  most  creditable  book  on  surgical  pathology,  and  the  most  beautiful  medical 
illustration  of  the  bookmakers'  art  that  has  ever  been  issued  from  the  American  press." 


SAUXDERS'    BOOKS    ON 


Dtirck  and  Hektoen's 

Special    Pathologic    Histology 

Atlas  and  Epitome  of  Special  Pathologic  Histology.     By  Dr.  H. 

Durck,  of  Munich.  Edited,  with  additions,  by  Ludvig  Hektoen,  M.  D., 
Professor  of  Pathology,  Rush  Medical  College,  Chicago.  In  two  parts. 
Part  I. — Circulatory,  Respiratory,  and  Gastro-intestinal  Tracts.  120 
colored  figures  on  62  plates,  and  158  pages  of  text.  Part  II. — Liver, 
Urinary  and  Sexual  Organs,  Nervous  System,  Skin,  Muscles,  and 
Bones.  123  colored  figures  on  60  plates,  and  192  pages  of  text.  Per 
part :   Cloth,  $3-00  net.     In  Saunders'  Hand-Atlas  Series. 

The  great  value  of  these  plates  is  that  they  represent  in  the  exact  colors  the  effect 
of  the  stains,  which  is  of  such  great  importance  for  the  differentiation  of  tissue. 
The  text  portion  of  the  book  is  admirable,  and,  while  brief,  it  is  entirely  satisfac- 
tory in  that  the  leading  facts  are  stated,  and  so  stated  that  the  reader  feels  he  has 
grasped  the  subject  extensively. 

William  H.  Welch,  M.  D., 

Professor  of  Pathology,  Johns  Hopkins  University ,  Baltimore. 

"  I  consider  Diirck's  'Atlas  of  Special  Pathologic  Histology,'  edited  by  Hektoen,  a  very 
useful  book  for  students  and  others.     The  plates  are  admirable." 

Sobotta  and  Hixber's 
Human  Histology 

Atlas  and  Epitome  of  Human  Histology.  By  Privatdocent  Dr. 
J.  Sobotta,  of  Wiirzburg.  Edited,  with  additions,  by  G.  Carl  Huber, 
M.  D.,  Professor  of  Histology  and  Embryology  in  the  University  of 
Michigan,  Ann  Arbor.  With  214  colored  figures  on  80  plates,  68 
text-illustrations,  and  248  pages  of  text.  Cloth,  $4.50  net.  /// 
Saunders1  Hand- Atlas  Series. 

INCLUDING    MICROSCOPIC   ANATOMY 

The  work  combines  an  abundance  of  well-chosen  and  most  accurate  illustra- 
tions, with  a  concise  text,  and  in  such  a  manner  as  to  make  it  both  atlas  and  text- 
book. The  great  majority  of  the  illustrations  were  made  from  sections  prepared 
from  human  tissues,  and  always  from  fresh  and  in  every  respect  normal  specimens. 
The  colored  lithographic  plates  have  been  produced  with  the  aid  of  over  thirty 
colors,  and  particular  care  was  taken  to  avoid  distortion  and  assure  exactness  of 
magnification.  The  text  is  as  brief  as  possible,  clearness,  however,  not  being 
sacrificed  to  brevity. 


PHYSIOLOGY.  13 


Howell's  Physiology 


American  Text=Book  of  Physiology.  In  two  volumes.  Edited  by 
William  H.  Howell,  Ph.D.,  M.  D.,  Professor  of  Physiology  in  the 
Johns  Hopkins  University,  Baltimore,  Md.  Two  royal  octavo  volumes 
of  about  600  pages  each,  fully  illustrated.  Per  volume  :  Cloth,  $3.00 
net;  Sheep  or  Half  Morocco,  $3.75  net. 

SECOND    EDITION,   REVISED   AND    ENLARGED 

Even  in  the  short  time  that  has  elapsed  since  the  first  edition  of  this  work 
there  has  been  much,  progress  in  Physiology,  and  in  this  edition  the  book  has  been 
thoroughly  revised  to  keep  pace  with  this  progress.  The  chapter  upon  the  Cen- 
tral Nervous  System  has  been  entirely  rewritten.  A  section  on  Physical  Chem- 
istry forms  a  valuable  addition,  since  these  views  are  taking  a  large  part  in  current 
discussion  in  physiologic  and  medical  literature. 

The  Medical  News 

"  The  work  will  stand  as  a  work  of  reference  on  physiology.  To  him  who  desires  to  know 
the  status  of  modern  physiology,  who  expects  to  obtain  suggestions  as  to  further  physiologic 
inquiry,  we  know  of  none  in  English  which  so  eminently  meets  such  a  demand." 

Stewart's  Physiology 


A  Manual  of  Physiology,  with  Practical  Exercises.  For  Students 
and  Practitioners.  By  G.  N.  Stewart,  M.  A.,  M.  D.,  D.  Sc,  Professor 
of  Physiology  in  the  University  of  Chicago,  Chicago.  Octavo 
volume  of  894  pages,  with  336  illustrations  and  5  colored  plates. 
Cloth,  $3.75  net. 

FOURTH    REVISED    EDITION 

This  work  is  written  in  a  plain  and  attractive  style  that  renders  it  particularly 
suited  to  the  needs  of  students.  The  systematic  portion  is  so  treated  that  it  can 
be  used  independently  of  the  practical  exercises,  which  constitute  an  important 
feature  of  the  book.  In  the  present  edition  a  considerable  amount  of  new  matter 
has  been  added,  especially  to  the  chapter  on  The  Central  Nervous  System. 

Philadelphia  Medical  Journal 

"  Those  familiar  with  the  attainments  of  Prof.  Stewart  as  an  original  investigator,  as  a 
teacher  and  a  writer,  need  no  assurance  that  in  this  volume  he  has  presented  in  a  terse,  concise, 
accurate  manner  the  essential  and  best  established  facts  of  physiology  in  a  mo;/  attractive 
manner." 


i4  SAUNDERS   BOOKS    ON 

Levy  and  Klemperer's 
Clinical  Bacteriology 

The  Elements  of  Clinical  Bacteriology.  By  Drs.  Ernst  Levy  and 
Felix  Klemperer,  of  the  University  of  Strasburg.  Translated  and 
edited  by  Augustus  A.  Eshner,  M.  D.,  Professor  of  Clinical  Medicine, 
Philadelphia  Polyclinic.  Octavo  volume  of  440  pages,  fully  illustrated. 
Cloth,  $2.50  net. 

S.  Solis-Cohen,  M.  D., 

Senior  Assistant  Professor  of  Clinical  Medicine,  Jefferson  Aledical  College,  Phila. 
"  I  consider  it  an  excellent  book.      I  have  recommended  it  in  speaking  to  my  students." 


Lehmann,  Neumann,  and 
Weaver's  Bacteriology 

Atlas  and  Epitome  of  Bacteriology :  including  a  Text-Book  of 
Special  Bacteriologic  Diagnosis.  By  Prof.  Dr.  K.  B.  Lehmann 
and  Dr.  R.  O.  Neumann,  of  Wiirzburg.  Eroni  the  Second  Revised  and 
Enlarged  German  Edition.  Edited,  with  additions,  by  G.  H.  Weaver, 
M.  D.,  Assistant  Professor  of  Pathology  and  Bacteriology,  Rush  Medical 
College,  Chicago.  In  two  parts.  Part  I. — 632  colored  figures  on  69 
lithographic  plates.  Part  II. — 511  pages  of  text,  illustrated.  Per  part: 
Cloth,  S2.50  net.     In  Saunders'  Hand-Atlas  Series. 

The  Lancet,  London 

"  We  have  found  the  work  a  more  trustworthy  guide  for  the  recognition  of  unfamiliar 
species  than  any  with  which  we  are  acquainted." 

Stengel  and  White  on  Blood 

The  Blood  in  its  Clinical  and  Pathologic  Relations.  By  Alfred 
Stengel,  M.  D.,  Professor  of  Clinical  Medicine  in  the  University  of 
Pennsylvania;  and  C.  Y.  White,  Jr.,  M.  D.,  Instructor  in  Clinical 
Medicine  in  the  University   of  Pennsylvania.      In  Preparation. 

This  work  will  deal  with  the  blond  in  its  clinical  and  pathologic  relations.  It 
will  be  beautifully  illustrated,  and  will  represent  the  latest  knowledge  on  the  sub- 
jects, concisely  and  clearly  expressed. 


PATHOLOGY,   BACTERIOLOGY,  AND    I'll  YSIOLOG  Y.  13 

Senil's    TlimOrS  Second  Revised  Edition 

Pathology  and  Surgical  Treatment  of  Tumors.  By  Nicholas 
Senn,  M.  D.,  Ph.  I).,  LL.D.,  Professor  of  Surgery,  Rush  Medical  Col- 
lege, Chicago.  Handsome  octavo,  718  pages,  with  478  engravings, 
including  12  full-page  colored  plates.  Cloth,  £5.00  net;  Sheep  or  Half 
Morocco,  $6.00  net. 

"  The  most  exhaustive  of  any  recent  book  in  English  on  this  subject.  It  is  well  illus- 
trated, and  will  doubtless  remain  as  the  principal  monograph  on  the  subject  in  our 
language  for  some  years.' — Journal  of  the  American  Me oical  Association. 

Stoney's  Bacteriology  and  Technic 

Bacteriology  and  Surgical  Technic  for  Nurses.  By  Emily  A.  M. 
Stoney,  Superintendent  of  the  Training  School  for  Nurses  at  the  Carney 
Hospital,  South  Boston,  Mass.  121110  of  200  pages,  profusely  illus- 
trated.    Cloth,  $1.25   net. 

"These  subjects  are  treated  most  accurately  and  up  to  date,  without  the  superfluous 
reading  which  is  so  often  employed.  .  .  .  Nurses  will  find  this  book  of  the  greatest  value." 
—  The  Trained  Nurse  and  Hospital  Review. 

Clarkson's  Histology 

A  Text-Book  of  Histology.  Descriptive  and  Practical.  For  the 
Use  of  Students.  By  Arthur  Clarkson,  M.  B.,  C.  M.  Edin.,  formerly 
Demonstrator  of  Physiology  in  the  Owen's  College,  Manchester,  Eng- 
land. Octavo,  554  pages,  with  174  colored  original  illustrations. 
Cloth,  $4  00  net. 

"  The  volume  in  the  hands  of  students  will  greatly  aid  in  the  comprehension  of  a  sub- 
ject which  in  most  instances  is  found  rather  difficult.  .  .  .  The  work  must  be  considered 
a  valuable  addition  to  the  list  of  available  text-books,  and  is  to  be  highly  recommended." 
■ — New  York  Medical  Journal. 

Gorham's  Bacteriology 

A  Laboratory  Course  in  Bacteriology.  For  the  Use  of  Medical, 
Agricultural,  and  Industrial  Students.  By  Frederic  P.  Gorham,  A.  M., 
Associate  Professor  of  Biology  in  Brown  University,  Providence,  R.  I., 
etc.      i2mo  of  192  pages,  with  97  illustrations.      Cloth,  $1.25  net. 

"  One  of  the  best  students'  laboratory  guides  to  the  study  of  bacteriology  on  the  mar- 
ket. .  .  .  The  technic  is  thoroughly  modern  and  amply  sufficient  for  all  practical  pur- 
poses."— American  Journal  of  the  Medical  Sciences. 

Raymond's  Physiology  ^^f£tl^°r- 

Human  Physiology.  By  Joseph  H.  Raymond,  A.  M.,  M.  D.,  Pro- 
fessor of  Physiology  and  Hygiene,  Long  Island  College  Hospital,  New 
York.      Octavo  of  668  pages,  with  443  illustrations.      Cloth,  $3.50  net. 

"The  book  is  well  gotten  up  and  well  printed,  and  may  be  regarded  as  a  trustworthy 
guide  for  the  student  and  a  useful  work  of  reference  for  the  general  practitioner.  The 
illustrations  are  numerous  and  are  well  executed." — The  Lancet,  London. 


16  BACTERIOLOGY,   PHYSIOLOGY,  AND  HISTOLOGY. 

Ball's    Bacteriology  Fourth  Edition,  Revised 

Essentials  of  Bacteriology  :  being  a  concise  and  systematic  intro- 
duction to  the  Study  of  Micro-organisms.  By  M.  V.  Ball,  M.  D.,  Late 
Bacteriologist  to  St.  Agnes'  Hospital,  Philadelphia.  i2mo  of  236  pages, 
with  96  illustrations,  some  in  colors,  and  5  plates.  Cloth,  $1.00  net.  In 
Saunders1  Question- Compend  Series. 

"  The  technic  with  regard  to  media,  staining,  mounting,  and  the  like  is  culled  from  the 
latest  authoritative  works." — The  Medical  Times,  New  York. 

Budgett's  Physiology 

Essentials  of  Physiology.  Prepared  especially  for  Students  of  Medi- 
cine, and  arranged  with  questions  following  each  chapter.  By  Sidney 
P.  Budgett,  M.  D.,  Professor  of  Physiology,  Medical  Department  of 
Washington  University,  St.  Louis.  i6mo  volume  of  233  pages,  finely 
illustrated  with  many  full-page  half-tones.  Cloth,  $1.00  net.  In 
Saunders'   Question- Compend  Series. 

"  Contains  the  essential  facts  of  physiology  presented  in  a  clear  and  concise  manner." — 
Philadelphia  Medical  Journal. 

LerOy'S    Histology  Second  Edition,  Revised 

Essentials  of  Histology.  By  Louis  Leroy,  M.  D.,  Professor  of 
Histology  and  Pathology,  Vanderbilt  University,  Nashville,  Tennessee. 
i2mo,  263  pages,  with  92  original  illustrations.  Cloth,  $1.00  net.  In 
Saunders'  Question-  Compend  Series. 

"  The  work  in  its  present  form  stands  as  a  model  of  what  a  student's  aid  should  be  ;  and 
we  unhesitatingly  say  that  the  practitioner  as  well  would  find  a  glance  through  the  book 
of  lasting  benefit." — The  Medical  World,  Philadelphia. 

Bastin's  Botany 

Laboratory  Exercises  in  Botany.  By  the  late  Edson  S.  Bastin, 
M.  A.,  Professor  of  Materia  Medica  and  Botany,  Philadelphia  College  of 
Pharmacy.     Octavo,  536  pages,  with  87  plates.     Cloth,  $2.00  net. 

"  It  is  unquestionably  the  best  text-book  on  the  subject  that  has  yet  appeared.  The 
work  is  eminently  a  practical  one." — Alumni  Report,  Philadelphia  College  of  Pharmacy . 

Frothingham's  Guide  for  the  Bacteriologist 

Laboratory  Guide  for  the  Bacteriologist.     By  Langdon  Froth- 

ingham,  M.  D.  V.,  Assistant  in  Bacteriology  and  Veterinary  Science, 

Sheffield  Scientific  School,  Yale  University.   Illustrated.   Cloth,  75  cts.  net. 

,.  .  — .        .       .     — ^.     ..  Fourth  Revised  Edition, 

American  Pocket  Dictionary  just  issued 

Dorland's  Pocket  Medical  Dictionary.  Edited  by  W.  A.  New- 
man Borland,  M.  D.,  Assistant  Obstetrician  to  the  Hospital  of  the 
University  of  Pennsylvania.  Containing  the  pronunciation  and  defini- 
tion of  the  principal  words  used  in  medicine  and  kindred  sciences,  with 
64  extensive  tables.  Handsomely  bound  in  flexible  leather,  with  gold 
edges,  $1.00  net ;  with  patent  thumb  index,  $1.25  net. 

"  I  can  recommend  it  to  our  students  without  reserve." — J.  H.  Holland,  M.  D.,  Dean 
of  the  Jefferson  Medical  College,  Philadelphia. 


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